Caring for the Deteriorating Patient

8:30am - Start of Day One

9:00am - Recognising and Responding to Clinical Deterioration

When nurses contribute to the identification, assessment and management of deteriorating patients, they can save lives, reduce unnecessary morbidity and length of stay in hospitals. Changes in clinical signs are often missed, misinterpreted or mismanaged.

• Who are the patients who are most at risk?
• Which factors impede the early identification and appropriate management of these patients?
• How helpful and widespread is the use of risk algorithms for providing early recognition 'alert data'?
• System and organisational approaches such as the staff skill mix use of clinical pathways tools and clinical risk management policies.

9:45am - Something is Wrong With This Patient - Looking For Clues

In inpatient settings, nurses are the 24-hours, front-line health care professional staff. If the patient is known to the nurse, then observations will include a comparison between the patient's current and previous health status.

Any signs and symptoms may be immediately observable or emerging. Vigilant monitoring for early detection includes how the nurse responds to the patient who states 'I don't feel well'. 

• Importance of listening to the patient, during a simple interaction, without interruption
• Seeking further clarification with key questions (What, Why, When and Where?) interpretation of obvious signs e.g. observing if the person is alert or lethargic or agitated
• Recognising other physiological markers such as:
  • the appearance of visible skin, e.g. wrinkled due to dehydration
  • reported levels of pain or feelings of pressure
  • and their anatomical locations

10:30am - Morning Tea & Coffee

11:00am - Physical Deterioration - Signals from the Vital Signs

'Almost half of the patients who die without 'not for resuscitation' order have serious and potentially reversible abnormalities in their vital signs in the 24 hours before death' 
- Source: Hillman et al, 'Antecedents to Hospital Deaths' (2001), Internal Medicine, 31:343-8.

• When a person's condition is deteriorating, what happens to the temperature, blood pressure, pulse and respirations to indicate that all is not well?
• Importance of knowing  that normal ranges for different ages and levels of fitness, what to expect with various activity levels, and how drugs can impact on the heart rate.
• Exploration of the changes in vital signs, including subtle variations, which indicate that a previously stable patient is becoming unstable. Examples of abnormalities include stertorous breathing and tachycardia / bradycardia.

12:30pm - Lunch Break & Networking

1:30pm - Other Assessment and Care Planning Considerations

This session will focus on the nurse's role with regard to a range of dangerous indicators, which may include:

• Trauma and shock
• Haemorrhaging
• Fever
• Fitting
• Decreased urinary output or urinary frequency
• Severe allergic reaction or anaphylaxis
• Infection and spsis
• Post-Operative malignant hyperthermia
• Adverse reactions to prescribed drugs, e.g. antibiotic sensitivity

Further treatment complications

• A comment on the need to ensure that monitoring equipment is not a source of false results
• The head-to-toe physical examination
• Medical investigations such as pathology / microbiology tests and diagnostic medical imaging procedures
• Care planning and clinical intervention decisions based on the assessment findings

3:00pm - Afternoon Tea & Coffee

3:30pm - Reporting Clinical Deteriorations

Timely reports of nursing observations are linked to timely interventions. In crisis situations written reports - and even charting - are deferred.

• What are crucial elements for communicating verbally with other members of the team?
• In non-emergency situations where the patient's health is compromised, what are useful tools for rapid and consistent charing of observations?
• Writing concise yet accurate progress notes that are informative and duty-of-care compliant
• Use of hand-held digital recording devices at the bedside
• The handover - updated and timely informatoin to facilitate the next shift of nursing staff
• Recognising and reporting escalation in the futher deterioration of a patient's condition

4:15pm - Close of Day One of Program

9:00am - Start of Day Two

9:00am - When Concurrent Mental Deterioration is the Problem

It may be that a patient has one or more physical problems, e.g. a broken leg and pneumonia with no deterioration in these problems. Instead, there is a psychiatric relapse or else the first emergence of mental instability.

Examples include marked post-operative confusion or paranoid ideas about the harmful intentions of the staff or prescribed medicines that cause psychiatric symptoms.

• How to conduct a rapid mental status assessment
• Under which circumstances are unpredictable aggressive incidents likely to occur?
• What is the role of the Liaison Mental Health Nurse in large, acute care hospital settings?

10:30am - Morning Tea & Coffee

11:00am - Every Minute Counts

'This patient's condition has reached a critical point'

'This patient appears to be deteriorating - what can I do?'

When and how to call for assistance for the deteriorating patient and in potentially life-threatening conditions.

• Making the Medical Emergency Team (MET) call
• The who, how and why of resuscitation issues including the difference between a MET call and a cardio/respiratory arrest call
• Role of the primary care nurse in 'arrest calls'
• What happens when there is no MET service?
• How to improve crisis response teamwork

12:00pm - Case Study and Discussion

Presentation of a complex case study, which illustrates key nursing responsibilities when a patient's condition is deteriorating.

Time for questions and comments

12:30pm - Lunch Break and Browse the Book Display

1:30pm - Caring for an Unconscious Patient

• Causes of sudden coma, e.g. diabetes or trauma
• Assessing levels of consciousness and other neurological signs, such as intracranial pressure
• The three components of Glasgow Coma Test (scores and the meanings of the score ratings)
• Nursing care and management essentials, including coma reversal phases

2:40pm - Attending to the Needs of Family and Friends

Discussion of what is appropriate when breaking bad news about the patient's condition to family members and/or close friends who are in attendance.

3:00pm - Afternoon Tea & Coffee

3:30pm - Still on the Danger List

Even though a patient's deteriorated condition has been reversed, the assault to physical and mental status may be such that the patient remains seriously ill. Delirium Tremens (DTs) is an example of an emergency situation where this may be the case. 

• Skills required in the conscientious monitoring and documentation of progress - or lack of progress
• Ongoing holistic re-assessment of mental and physical functions
• Appropriate crisis interventions for any rapid retrogression
• The nurse's role when a patient is dying due to irreversible deterioration

4:15pm - Close of Program and Evaluations