Advanced patient assessment

Recognising physiological deterioration
The onset of clinical deterioration refers to the stage when the person’s clinical state becomes physiologically unpredictable and unstable. It can result in incapacity or
death within minutes or hours. Several conditions can lead to sudden and/or unexpected deterioration of patients, and clinicians must possess knowledge and clinical
experience of specific critical illness states to be able to identify key early warning signs and symptoms indicating physiological deterioration.
The clinical signs of critical illness and deterioration are usually similar regardless of the underlying cause, because they reflect compromise of major body systems. The
identification of abnormal clinical signs [together with the patient’s history, examination and appropriate investigations] is central to objectively identifying patients who are
at risk of deterioration. These signs and symptoms are often subtle and can go unnoticed. Therefore developing assessment skills that are alert to the signs and risk of
deterioration in a patient is essential in specialist clinical practice.
Learning Outcomes
Upon successful completion of this section, you should be able to:
explain the importance for the assessment of critically ill patients
describe the key elements of advanced clinical assessment
describe the principles and practice of clinical assessment
understand the importance of recognising and preventing further deterioration in patient care
Early recognition of clinical deterioration, followed by prompt and effective action, can minimise the occurrence of adverse events s
uch as cardiac arrest, and may mean that a lower level of intervention is required to stabilise a patient.
Prevention of deterioration that results in respiratory and cardiac arrest represents the most important and most effective step in the chain of survival. It is widely
recognised that cardiac arrest in patients in unmonitored ward areas most commonly occur following a period of progressive physiological deterioration rather than a
sudden unpredictable event.
The consensus statement of the Australian Quality and Safety Health Care Commission (2010) recommends that all facilities have systems in place for measurement and
documentation of vital signs and escalation of care including rapid response systems with organisational support.
Nature of the deficiencies in the recognition and response to patient deterioration often include: infrequent, late or incomplete vital signs assessments; lack of knowledge
of normal vital signs values; poor design of vital signs charts; poor sensitivity and specificity of ‘track and trigger’ systems; failure of staff to increase monitoring or
escalate care, and staff workload. There is also often a failure to treat abnormalities of the patient’s airway, breathing and circulation, incorrect use of oxygen therapy,
poor communication, lack of teamwork and insufficient use of treatment limitation plans.
One of the most important directives of the ARC Guidelines include increased emphasis on the use of ‘track-and-trigger systems’ to detect the deteriorating patient and
enable treatment to prevent in-hospital cardiac arrest in order to improve survival.
Figure 1: Early recognition and access are essential components of effective resuscitation
The Chain of Survival represents the link between the essential elements in resuscitation which, if performed effectively, can lead to an increase in the number of persons
who survive a cardiac or respiratory arrest.
Zimlichman: Early recognition of patien…
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Triage, by definition, is a dynamic process, as the patient’s status can change rapidly. Patients may enter the triage stream at any point—
for example, patients with critical illness and injury not infrequently walk in to emergency departments. Even though Pre-hospital and ED
locations use Triage processes continuously, the process and concept should be used continuously with all patients at risk of deterioration
in all clinical areas. At each stage of the triage process, certainty can be added by measurement of physiological parameters and the
introduction of structured clinical examination. Triage may be either focused or comprehensive. Comprehensive triage refers to taking a
complete history, checking vital signs, determining allergies, and, where appropriate, performing a physical examination. Focused triage is
generally used for more minor illnesses or injuries and includes a more limited history and screening prior to assessing patient priority.
Triage is essential for the early recognition of the seriously ill patient and rapid initiation of therapy, which reduces morbidity and mortality.
Triage means sorting and treating patients according to priority. Primary and Secondary Survey follow after the sorting of patients
according to priority, but in reality the primary survey is often performed simultaneously with Triage or immediately and rapidly after.
In Australia the Australasian Triage Scale (ATS) is predominantly used. The ATS has five levels of acuity:2 • Immediately life-threatening
(category 1) • Imminently life-threatening (category 2) • Potentially life-threatening or important time-critical treatment or severe pain
(category 3) • Potentially life-serious or situational urgency or significant complexity (category 4) • Less urgent (category 5).
Table 1: ATS categories for treatment acuity and performance thresholds
Key Points:
Identifying and managing risks to self, patients and the environment is the first principle of safe triage practice and is relevant to all clinical
practice not only the ED and Pre-hospital areas. The primary survey approach is used to identify and correct life-threatening conditions at
Paediatric Physiological Discriminators
The clinical priorities and the principles of urgency for infants, children and adolescents are the same as those for adults.
• Determining urgency will require recognition of serious illness, some features of which may be different in infants and children.
• The value of parents and their capacity to identify deviations from normal in their child’s level of function should not be underestimated.
Refer to the Reading “Emergency Triage Education Kit” Commonwealth of Australia 2009. for more comprehensive outline of Triage.
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  1. “Emergency Triage Education Kit” Commonwealth of Australia 2009 – Click Here This includes both Adult and Paediatric Triage, Primary
    Survey and Secondary Survey.
  2. ACCCN National Adult Advanced Life Support Program Manual – Section three; pp 11-12
    3.. Aitken, A, Marshall, A, & Chaboyer, W., 2015, ACCCN’s critical care nursing, 3nd edn, Elsevier, Australia, Chapter 23, pp 739-745. Each
    system based chapter incorporates an assessment chapter prior to or included in the management chapter. Refer to these for specific
    systems assessment.
    4., Bickley, Lynn S., and Szilagyi, Peter G. 2013, Chapter 3, Beginning the Physical Examination: General Survey and Vital Signs in Bates’
    Guide to Physical Examination and History Taking / Lynn S. Bickley. Peter G. Szilagyi. 10th ed. Philadelphia: Lippincott Williams & Wilkins. –
    eReading – Click Here
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    The initial assessment and management of an acutely ill patient is one of the most challenging tasks that a clinician can undertake. Decisions must be made and actions
    performed rapidly in conditions of uncertainty. There can be uncertainty about the disease process, the correct interventions, the likely outcome, and one’s own abilities to
    manage the situation appropriately. In this environment, a structured approach to providing safe care is essential.
    ‘Patients do not die of their disease. They die of the physiologic abnormalities of their disease’
    Sir William Osler
    Between these two extremes however, is the complex and non-linear problem of the acutely ill or deteriorating patient. For management of these patients, there is no
    standardised management protocol or comforting algorithm to follow.
    An continual approach involves initial identification of physiological abnormality, initiation of treatment and repetitive review while conducting other tasks to define the
    diagnosis and treatment. Traditional approach is more lineal
    The continuous model requires that initial treatment precedes diagnosis. Using this approach to managing the acutely ill patient, a clinician must be able to prioritise
    issues in relation to clinical care. Neither a patient with a known diagnosis who dies from inadequately treated physiological abnormalities, nor a patient who is made
    physiologically stable but then subsequently dies due to lack of specific treatment for the underlying disease process is a satisfactory clinical outcome. The central point is
    the importance of establishing and maintaining a safe environment for the patient through immediate evaluation and manipulation of physiology to optimise tissue oxygen
    This approach has several important merits. First, it makes clinicians attend to the essential task of optimising tissue oxygen supply. Second, unlike the traditional
    method, the requirement to’fix the physiology’ reduces the number of possible problems and interventions to manageable proportions. This simplifies initial management
    and reduces opportunities for error. Diagnostic possibilities begin to open up with the process of iterative review, and then close down as information is obtained from the
    history, laboratory tests, and from monitoring the response to treatment. The third advantage is that it makes clinicians focus on global aspects of patient safety as a
    primary goal, rather than on the diagnosis as an end in itself.
    Elective medical care follows the traditional, comparatively leisurely, pathway of taking a history, performing an examination, arranging laboratory investigations to
    confirm or refute a diagnosis, starting treatment, and evaluating outcomes (see traditional linear approach, below). Emergency care is less predictable, but within
    this arena some clinical activities, trauma care and cardiopulmonary resuscitation for example, have developed management strategies which reduce the clinical
    problems to their basic elements using well-established algorithms.
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    Phases of Care in clinical assessment – Click Here
    (Adapted from “Clinical Examination” ESICM
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    Advanced patient assessment skill is part of the surveillance skills that specialist nurses develop to recognise the patient at risk of deterioration.
    E = ENVIRONMENT & EXCRETION (Both internal – fluids and electrolyte and external – clear surroundings related to danger)
    Secondary survey and comprehensive general patient assessment
    This refers to a more general assessment rather than a surveillance tool such as primary survey..
    This includes presenting problems, drugs and diagnostic tests, equipment and technological devices and allergies. A full safety check of
    the patient and the patient environment especially at the beginning of patient care is routine. Then a thorough head to toe, system by
    system assessment process is performed including psychosocial assessment.
    Primary Survey as surveillance method
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    Critical Care Assessment
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    The pediatric primary survey is an approach for a comprehensive, hands-on assessment of an ill or injured child regardless of complaint.
    As in adults, the primary
    survey provides a specific sequence for treating life-threatening problems as they are identified, before moving to the next step. The steps
    in the survey are the same as with adults, but there are differences in the specific signs of distress or physiologic instability.
    Characteristics of appearance
    The child’s general appearance is the single most important parameter when assessing severity of illness or injury. Appearance reflects
    the adequacy of ventilation, oxygenation, brain perfusion, body homeostasis and CNS function. It is more accurate than any other clinical
    characteristic of the patient in predicting overall distress, need for treatment and response to treatment.
    Components of appearance are : Tone, Interactability, Consolabilty, Look/Gaze, and Speech/Cry.
    Figure 1: Components of appearance summarised.
    Components of the pediatric primary survey: airway and breathing
    First determine airway patency by observing work of breathing and listening for abnormal audible breath sounds such as stridor, wheezing
    and grunting as part of
    performing the PAT. The loudness of the stridor or wheezing is not strongly correlated with the degree of airway obstruction. For example,
    asthmatic children in severe distress may have little or no wheezing. Similarly, children with an upper airway foreign body below the vocal
    cords may have minimal stridor. Abnormal breath sounds merely indicate whether there is any degree of upper or lower airway
    Figure 2: Airway sounds summarised
    Figure 3: Skin color summarised
    Figure 4: Work of breathing summarised
    Also, evaluate tidal volume and effectiveness of work of breathing, by listening for air movement bilaterally over the midaxillary line. A
    child with increased
    work of breathing and poor tidal volume may be in impending respiratory failure.
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    Determine the respiratory rate, but interpret the respiratory rate cautiously. Rapid rates may simply reflect high fever, anxiety, pain or
    excitement. Normal rates, on the other hand, may occur in a child who has been breathing rapidly for some time to overcome an airway
    obstruction and is now becoming fatigued. Finally, interpret respiratory rate in light of what is normal for age. A very rapid respiratory rate
    (>60/min for any age), especially in association with abnormal appearance or marked retractions, indicates respiratory distress and
    possibly failure. An abnormally slow respiratory rate is always worrisome and suggests respiratory failure. Red flag respiratory rates are
    <20/min for child <2 years, and <10 for children >2 years.
    Frank cyanosis is a late finding. A hypoxic child is likely to show other abnormalities, such as increased work of breathing, agitation or
    lethargy long before they look “blue”. Do not wait for cyanosis to initiate treatment with supplemental oxygen. However, if cyanosis is
    present, immediately intervene.
    Components of the pediatric primary survey: circulation
    Next, assess circulation. Appearance will have provided important visual clues about adequacy of circulation. Appearance and work of
    breathing may also be altered if the child is in shock. Appearance will be abnormal because of inadequate perfusion of the brain. The
    combination of abnormal appearance and decreased circulation to skin suggests shock, either compensated or decompensated.
    However, abnormal appearance may also result from many severe stress states, such as hypoxia, hypercarbia, head trauma, infection, or
    drugs. In addition, sometimes children in shock seem remarkably alert, although careful observation of appearance will always indicate
    some abnormality such as listlessness or restlessness.
    Children in shock will often be tachypneic, without retractions, as they attempt to compensate for metabolic acidosis (due to poor
    perfusion) by blowing off CO2. This pattern of rapid respiration may be termed “effortless tachypnea”, and is distinct from the rapid
    labored respirations with retractions seen with underlying airway/breathing problems.
    Heart rate (HR) and blood pressure (BP) have a limited but still useful role in evaluating core circulation. Parameters commonly used to
    assess adult circulatory status, i.e. HR and BP, have important limitations in children. First, normal HR varies inversely with age. Second,
    tachycardia may be an early isolated sign of hypoxia or low perfusion, but, it may also be present because of benign conditions such as
    fever, anxiety, pain and excitement. HR must therefore be interpreted in the context of the overall history, PAT and comprehensive
    physical exam. A trend of increasing or decreasing HR may be quite useful, and may suggest worsening hypoxia or shock, or
    improvement after treatment.
    When hypoxia or shock becomes critical, HR falls to frank bradycardia. Bradycardia means critical hypoxia and/or ischemia. When the HR
    is above 180/min, HR cannot be accurately determined without the assistance of an electronic monitor.
    BP determination is difficult in children because of lack of cooperation, difficulty remembering the proper cuff size and errors in
    interpretation. For patients less than three years of age these technical difficulties reduce the value of a BP. When shock is suspected in
    this age group based on other parameters (e.g., history, mechanism, PAT), attempt BP once, but do not delay management further.
    BP may be misleading. Although a low BP definitely indicates decompensated shock, a “normal” BP frequently exists in compensated
    shock. An easy formula for determining the lower limit of acceptable blood pressure by age is: minimal systolic blood pressure = 70 + 2 x
    age (in years).
    Circulatory assessment also entails further detection of signs of decreased circulation to skin. This includes hands-on evaluation of skin
    temperature, capillary refill time (CRT) and pulse quality. To quickly assess circulation, lay your hand on the kneecap or forearm and feel
    for skin temperature. Be sure the child is not cold from exposure, because skin signs will be deceptive if the child is not warm.
    Next, feel the pulse and check the capillary refill time (CRT). Signs of circulation to the skin, i.e. skin temperature and color, CRT, and
    pulse strength, are tools to assess a child’s circulatory status, especially when performed serially on a child who is not cold. In a normal
    infant, you can easily palpate the brachial pulse, the extremities are warm and have a uniform color (not “mottled”), and the CRT is less
    than two seconds.
    Figure 5 : Summary of circulation assessment
    Components of the pediatric primary survey: disability or neurological status
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    Assessment of neurologic status involves rapid evaluation of both cortical and brainstem function. Assess neurological status by
    observation of appearance, pupillary responses to light, level of consciousness, and motor activity. In the
    evaluation of motor activity, assess purposeful movement, symmetrical movement of extremities, seizures, posturing, or flaccidity.
    The AVPU pneumonic is a rapid method of assessing level of consciousness that is quite consistent with different observers. It
    categorizes motor response based upon simple responses to stimuli. The child is either Alert, responsive to Verbal stimuli, responsive
    only to Painful stimuli, or Unresponsive.
    Figure 6: AVPU summarised
    Abnormal appearance and altered level of consciousness
    A child with altered level of consciousness on the AVPU will always have abnormal appearance, because any patient so sick that she is
    no longer “alert” and will only respond to verbal stimuli is already moderately to critically ill. Therefore, the signs of abnormal appearance
    are most useful in identifying distress in the alert child who has mild to moderately severe distress. The AVPU is simply not a very
    sensitive method to identify children in early stages of system stress from illness or injury. Assessing appearance using the characteristics
    as described for the PAT allows a more subtle appreciation of compensated illness and injury, facilitates early intervention and averts
    progression to more advanced states of neurologic
    deterioration on the AVPU scale. A child who has an abnormal appearance or who is not alert on the AVPU, yet has no increased or
    decreased work of breathing or abnormal circulation to skin, probably has a focused insult to the brain.
    As in adults, vital signs can impart important information. Obtaining and interpreting vital signs in children however may present more
    difficulty because it is difficult to obtain accurate values. Children may be uncooperative and properly sized equipment may not be
    available. Normal values vary with age, making recognition of abnormalities more challenging. Remember, vital signs are just a piece of
    the overall clinical picture, which includes history of illness, mechanism of injury, and a comprehensive clinical evaluation. Often using an
    approach of Appearance, Work of Breathing and Circulation to the Skin can help priortise in a timely way the urgent needs of a
    child or infant.
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    This module content pertains to the assessment of the deteriorating adult and child. It provides a primary and secondary assessment
    framework. Continue now with the tutorial as a question and answer session that role plays the management of a deteriorating patient.
    Attend a class or listen to the online class to consolidate your learning.

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