Lorraine Hameiri 2017-8

1. סיעוד במצבים דחפיםTriage skillsandIdentification and management of the acutely deteriorating hospital patientfor nursing students. Lorraine Hameiri 2017-8

2. הרצאה 2כלים לטראז' וזהיוי החולה הלא יצב שמתדרדר • Assessment skills are used to determine the severity of the new ER patient’s condition.This is the triage process • These same assessment skills are used to recognize instability and deterioration in the hospitalized patient.

3. Course objectives To understand assessments used in both: • Triage in the ER • Use triage principles in recognizing deterioration of hospitalized patients

4. Assessment is איסוף נתונים משני סוגים: • נתונים סובייקטיביים • נתונים אובייקטיביים The data need to be collected rapidly and systematically

5. נתונים סובייקטיביים הכוונה למידע הנמסר על ידי החולה, על ידי בני משפחתו או על-ידי אנשים אחרים שיש בידם מידע רלוונטי.

6. נתונים אובייקטיביים הכוונה למידע שישנה אפשרות לצפות בו או למדוד אותו. זהו מידע עובדתי המשמש לאימות הנתונים הסובייקטיביים. להלן דוגמאות של מידע אובייקטיבי: • סימנים חיוניים • בדיקה פיזיקלית • תוצאות בדוקות מעבדה ואחרות

7. נתונים סובייקטיביים ונתונים אובייקטיביים מהווים יחדיו בסיס לאומדן מצבו של החולה.

8. חשיבה קריטית וקלינית היא: תהליך הנעשה לאחר איסוף כל המידע הסובייקטיבי והאובייקטיבי לצורך ביצוע הטריאג' טריאג הינו תהליך אומדן שיטתי מהיר אותו יש ללמוד

9. Universal Precautions • Hand washing • Gloves / gown / mask / protective eyewear • Remove clothes carefully because of syringes and needles in pockets • Don’t recap needles • Refrain from direct contact with body fluids • Hepatitis B vaccine

10. אומדן ראשוני מהירRapid Primary Assessment(for the non-trauma patient)

11. אומדן ראשוני מהירPrimary assessment המטרה: להבטיח זיהוי מצבים שיש בהם סכנת חיים וטיפול בהם. מרכיבים: • A- Airway דרכי נשימה • B-Breathingנשימה • C- Circulation סירקולציה • D- Disability – neurological assessment • E-Exposure

12. SURVIVAL CHAIN

13. A-AIRWAY(upper)

14. Cervical spineC1-C2-C3 effect breathing

15. A:Airway (upper)+ Cervical Spine Assessment: Open clear airway Subjective Data: • No history airway problem • No dyspnea or dysphasia Objective Data: • Able to speak (appropriate sounds for age) • No foreign material in upper airway (blood, vomitus, loose teeth) • Chest rises and falls easily

16. Assessment: c/spine acceptable Subjective Data: • No history of degenerative bone disease • No complaints of pain on movement or palpation of neck, or breathing Objective Data: • Sensation of movement in all extremities without limitation or weakness.No difficulty with breathing

17. A – no threat : Proceed to B

18. Assessment: Compromised airway Subjective Data: • Patient eating when difficulty began • Recent vomiting • Contact with allergens • Patient with object in mouth • Difficulty swallowing

19. Assessment: Compromised airway (cont.) Objective Data: • Substernal intercostals retractions • Drooling • Difficulty swallowing • Nasal flaring • Violent coughing • Sitting up, leaning forward • Decreased level of consciousness • Stridor • Panic behavior • Unable to speak (cry) • Cyanosis (Late sign-extremely worrying sign) • Absence of breathing

20. PARTIAL AIRWAY OBSTRUCTION IS NOISY LOOK Distress Choking Difficulty breathing LISTEN Noisy breathing(stridor,snoring,wheezing) Choking sounds FEEL Some air movement at patient’s mouth or nose

21. COMPLETE AIRWAY OBSTRUCTION IS SILENT LOOK Distress Choking Difficulty breathing LISTEN No audible breath sounds FEEL NO air movement at patient’s mouth or nose

22. Etiology of Upper Airway Obstruction • Tongue falls back • cardiac arrest coma • Saliva / sputum • Vomitus • Blood • Loose teeth • Food • Foreign bodies / objects • Trauma to upper airway • Airway edema • vocal chords / larynx / trachea • infection anaphylaxis

23. Assessment: Cervical spine compromised Subjective Data: • Numbness/tingling/neck pain • Breathing difficulties Objective Data: • Paralysis • Breathing difficulties (May suggest a neurological disease process implicating cervical spine)

24. CALL FOR HELP ! Don’t leave the patient alone Use emergency button or call for help as per your institutions protocol Know your institutions protocol ! Don’t feel that you are expected to manage a sick patient by yourself. Most of the time there is other staff around. With a deteriorating patient it is expected that you call for assistance. You are not incompetent when you call for help. Your professional credibility is not threatened even if you assess incorrectly Do not fear looking stupid, Do not fear ridicule and being reprimanded. The staff culture is to support teach and respect the new nurse. Think firstly about the welfare of the patient not yourself It is better to call for help than delay , or not report deterioration because you are unsure of your assessment findings Many nurses feel anxious when a patient deteriorates.This is normal.Accept this.But do not allow your anxiety to delay calling for assistance

25. CALL FOR HELP IIDENTIFY : YOUR SELF AND THE PATIENT S SITUATION : CURRENT PROBLEM B BACKGROUND : WHY WAS PATIENT ADMITTED,RELEVENT MEDICAL AND SOCIAL HISTORY A ASSESSMENT FINDINGS IN PROFESSIONAL LANGUAGE R Recommendations : WHAT YOU WILL DO WHAT YOU WANT COLLEGE TO DO

26. Commence resuscitation Nursing role

27. Airway, Cervical Spine Resuscitation 1. Open airway: jaw thrust / chin lift / head tilt (if no c. spine implication) jaw thrust or chin lift only (if possible spinal involvement) patient on backboard / straps / rigid cervical spine collar

29. 2. Remove any loose objects or foreign debris that can be visualized 3. Suction gently to clear airway (deep suctioning may stimulate gag reflex)

30. 4. Oro-pharyngeal airway Only in unconscious patient (may stimulate vomiting or laringospasm in conscious patient) PREVENTS TONGUE BLOCKING AIRWAY .

31. Size is determed by measuring the airway on side of the face.Lip to ear.

34. 5.Nasopharyngeal airway In conscious or semi-conscious patients when oro-pharyngeal airway is unable to be placed eg. swelling to lips or mouth.

36. 6. For foreign objects-first encourage patient to cough then- Back blow, abdominal thrust

37. Team work 7. Assist endo tracheal intubation

38. Indications for intubation Unconscious patient with poor airway control. Establish airway for those who cannot be ventilated with an oropharangeal airway. Facilitate removal of tracheobronchial secretions To prevent aspiration. To bypass upper airway obstruction.

39. 8. Assist needle cricothyrotomy • Indicated when et-intubations difficult, e.g. edema (tube cannot be passed through chords),trauma,bleeding. • Needle passed through cricothyroid membrane into trachea, below level of obstruction. • Oxygen connected to needle.

40. 9. Assist surgical cricothyrotomy • Indicated when ET tube cannot be passed. • Cricothyroid membrane is opened with scalpel and ET tube tracheotomy tube inserted. • Ventilate patient with bag.

41. 10. Assist tracheotomy Indicated when unable to perform ET intubations or needle or surgical cirothyrotomy. Not common in emergencies. • associated with heavy bleeding • too time consuming • difficult to perform • Need to do in operation room

44. During the resuscitation try to take a rapid concise history-”what happened?” Support family

45. Following airway resuscitation assess patient for improvement or deterioration. Reassess after intervention then proceed. Desired outcomes: The patient will maintain a patent airway as evidenced by • Regular rate, depth and pattern of breathing • Bilateral chest expansion • Absence of signs and symptoms of airway obstruction, stridor, dyspnea, hoarse voice

46. B – Breathing Satisfactory Subjective Data: • No respiratory distress • No deviation from patients usual breathing pattern Objective Data: • Look: Chest rises and falls spontaneously • colour pinkish • Listen: Exhaled air can be felt or heard • Feel: Escaping from nose, mouth (or stoma) • Quality is smooth, even If breathing acceptable assess circulation.

47. If compromised Breathing: Immediate intervention before progressing to “C” Subjective Data: • Dyspnea • History of asthma, COPD, heart disease, respiratory arrest • Data from Pt, family, other?

48. Objective Data: • LOOK • Agonal breathing( <10/min > 30/min) • Cyanotic,(Central)late sign • Uneven rise and fall of chest • Use of accessory muscles of respirations • LISTEN • Unable to talk • Noisy breath sounds • Unable to cough • FEEL • Tracheal position,surgical emphysema

49. CALL FOR HELP ! Don’t leave the patient alone Use emergency button or call for help as per your institutions protocol Know your institutions protocol ! Don’t feel that you are expected to manage a sick patient by yourself. Most of the time there is other staff around. With a deteriorating patient it is expected that you call for assistance. You are not incompetent when you call for help. Your professional credibility is not threatened even if you assess incorrectly Do not fear looking stupid, Do not fear ridicule and being reprimanded. The staff culture is to support teach and respect the new nurse. Think firstly about the welfare of the patient not yourself It is better to call for help than delay , or not report deterioration because you are unsure of your assessment findings Many nurses feel anxious when a patient deteriorates.This is normal.Accept this.But do not allow your anxiety to delay calling for assistance

50. CALL FOR HELP IIDENTIFY : YOUR SELF AND THE PATIENT S SITUATION : CURRENT PROBLEM B BACKGROUND : WHY WAS PATIENT ADMITTED,RELEVENT MEDICAL AND SOCIAL HISTORY A ASSESSMENT FINDINGS IN PROFESSIONAL LANGUAGE R Recommendations : WHAT YOU WILL DO WHAT YOU WANT COLLEGE TO DO