Acute Nursing Care

Recognising and Responding to Medical Emergencies

Helen Dutton, Ian Peate, Helen Dutton, Ian Peate

• Publisher: Routledge
• Year: 2020
• ISBN:
  9780429786471
• Edition: 2
• Topic: Medizin
• Subtopic: Gesundheitsversorgung

Delays in recognising deterioration, or inappropriate management of people in acute care settings can result in late treatment, avoidable admissions to intensive care units and, in some instances, unnecessary deaths. As the role of the nurse in healthcare settings continues to change and evolve, today's nursing and other healthcare students need to be equipped with the fundamental skills to recognise and manage deterioration in the patient in a competent and confident manner, appreciating the complexities of caring for those who are acutely unwell as you learn to become practitioners of the future.

Using a body systems approach, and fully updated in light of new NEWS2 and NMC future nurse standards, as well as acknowledging the challenges faced by people with delirium in acute care settings, the second edition of this book provides a comprehensive overview of the essential issues in this important subject. Topics covered include recognition and identification of physiological and mental deterioration in adults; identification of disordered physiology that may lead to a medical emergency linked to deterioration of normal function; relevant anatomy and physiology; pathophysiological changes and actions that need to be taken; immediate recognition and response; investigations, diagnosis and management issues; and teaching and preventative strategies.

Including case studies and test yourself questions, this book is an essential tool for student nurses who are required to undertake acute care experiences and are assessed in theory and practice.

1 Assessment and recognition of emergencies in acute care

Helen Dutton

Aim

This chapter aims to give the reader an insight into the assessment and early identification of risk of clinical deterioration, and the skills required to escalate care in an appropriate and timely manner.

Objectives

After reading this chapter you will be able to:

• Give an overview of developments to date aimed at supporting the adult who has the potential to become acutely unwell.
• Understand that there are usually clinical signs of deterioration many hours before most life-threatening events.
• Use the National Early Warning Score (NEWS) 2 as a tool to calculate risk, escalate care and become familiar with interdisciplinary communication tools, such as SBAR.
• Perform, analyse and interpret a rapid clinical assessment of a patient who is at risk of deterioration/medical emergency.
• Understand how a ‘chain of prevention’ can be used to structure processes to detect patient deterioration.
• Have a context on which to base future chapters in recognising and responding to medical emergencies.

Introduction

The ultimate medical emergency, cardiopulmonary arrest, has long been the focus of education and training of health care professions. Resuscitation teams were formed as early as the 1930s, although it was not until 1966 that the first cardiopulmonary resuscitation (CPR) guidelines were published. Guidance on CPR continues to be updated every five years and is available at https://www.resus.org.uk. Techniques in addressing cardiopulmonary arrest are improving but results remain disappointing, with survival rates to discharge for in-hospital arrests at 20.4% (National Cardiac Arrest Audit 2017). Previously, much attention was placed on after-arrest care; more recently, however, the emphasis has shifted towards recognising those patients who are at risk of deterioration, with the aim of preventing medical emergencies, such as cardiac arrest, occurring. Expert advice, in the form of medical emergency teams (MET) and/or outreach services, is now a key feature in acute trusts, alongside tools that identify those at greatest risk of deterioration. The aim is to recognise those at increased risk and to provide timely interventions to prevent deterioration.

Recognition of the problem

Patients who deteriorate and present as a medical emergency require critical care. Whatever the cause or precipitating factor of a medical emergency, the physiological consequences for the patient are similar. Medical emergencies affect oxygen delivery to cells, tissues and organs. Oxygen is essential for glucose metabolism and ATP production as, without oxygen cellular and organ dysfunction, failure and death will inevitably ensue. Prompt responses are required to support failing organs until recovery or death, and this often requires the support of critical care services.

The problem is not a new one, with a number of studies in the 1990s highlighting problems with the recognition and management of the acutely unwell patient on adult wards (Goldhill et al. 1999; Schein et al. 1990; McQuillan et al. 1998) The evidence indicated that patients who deteriorate do not normally do so ‘out of the blue’ but have abnormal clinical parameters often some hours before the presentation of a medical emergency. Findings, such as abnormal respiratory rate, heart rate, adequacy of oxygenation or deteriorating mental status, were strong indicators that a patient was at risk of clinical deterioration. The conclusion drawn from these and other studies was that, if the patient had been identified and treated appropriately earlier, it was likely that the emergency may have been prevented.

Early identification

Although most people in hospital are unlikely to become seriously unwell, a significant number will require interventions in order to prevent or treat acute illness. Individuals move from experiencing minor physiological derangements through a period of deterioration and more serious illness, which, if left undetected and untreated, may progress to a life-threatening medical emergency, culminating in cardiopulmonary arrest. As people move along this continuum of wellness to the stage where death is imminent, they will be experiencing major physiological changes. The body will be attempting to restore homoeostasis by the activation of compensatory mechanisms, such as increased breathing rate or heart rate. These compensatory mechanisms in themselves require additional energy, placing extra physiological demands on the individual. In the early stages of acute illness, these mechanisms may be sufficient to meet the extra demands, healing may occur and the problem resolve. However, if the underlying problem remains untreated, or is unresponsive to treatments, deterioration will continue. There may be a rapid progression of severity of illness resulting in cardiac arrest. Clinical assessment will detect these physiological changes, but the information gained needs to be understood and acted upon to prevent the progression of illness. Examples of acute illnesses that may or may not deteriorate to a medical emergency are included in Table 1.1.

Table 1.1 Examples of acute illnesses that may lead to a medical emergency. Note how compensatory mechanisms of increased RR, HR and decreased adequacy of oxygenation are a feature of most examples

Example of acute illness	Physiological derangements and clinical consequences	Signs of compensation that may be evident
Airway swelling	Airway obstruction Failure to ventilate causing hypoxaemia and hypercarbia	Raised HR and blood pressure Intercostal retraction
Acute asthma	Bronchoconstriction reducing airflow through bronchioles and alveoli. Work of breathing increased. Sp02 falls, hypercarbia may follow	Raised respiratory rate, HR, BP Use of accessory muscles
Pneumothorax	Presence of air in the pleural space, leading to lung collapse Pain Hypoxaemia	Sensation of breathlessness, Use of accessory muscles increasing RR, HR and BP
Myocardial infarction	Death of myocardium due to blockage of a branch of a coronary artery Pain	Raised RR, HR, BP, peripheral vasoconstriction.
Acute left ventricular failure	Failure of the left ventricle to pump blood effectively into the aorta and round the body. Pulmonary venous pressures rise, causing the development of pulmonary oedema, hypoxaemia, frothy sputum	Profound respiratory difficulty and distress Raised RR & HR Use of accessory muscles, peripheral vasoconstriction.
Hypovolaemic shock	Reduction of amount of blood/fluid in the circulation Hypoxaemia	Raised respiratory rate, lowered HR, lowered BP, peripheral vasoconstriction
Sepsis	A dysregulated response to infection causing organ damage Inflammatory mediators cause vasodilation and increased capillary permeability	‘New confusion’ Raised HR, RR Warm and dilated peripheries Lowered BP

Understanding that signs of compensation may be indicative of acute illness, with the risk of rapid deterioration, helps the nurse interpret the vital signs recorded, so problems can be addressed early in the continuum of deterioration, averting the medical emergency. Unfortunately, this is not always the case; when problems are recognised, the appropriate treatment and management is not always followed, adversely affecting patient outcome.

The changing nature of acute health care delivery

Over the past few decades, the emphasis has moved from hospital care towards managing health care in the pri...