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Early recognition of the deteriorating patient

Nurses   (15,976 Views | 13 Replies)

CO2emission has 30 years experience and specializes in ICU, Paeds ICU, Correctional, Education.

2,539 Profile Views; 100 Posts

Evidence suggests that patients show signs of deterioration up to 8 hours before they actually become unstable and proceed on to cardiac arrest if not treated in that 10 minute window of instability.

How do you know your patient is deteriorating before this period of instability?

What barriers in the workplace and culture inhibit early recognition of deterioration?

Thanks for your thoughts.:nurse:

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JeanineLPN1984 has 23 years experience and specializes in LTC, Medicare visits.

56 Posts; 1,961 Profile Views

In LTC the changes are usually subtle, esp in the confused. Early signs of CHF in them start with anxiety before the edema or lung sounds. Some of the ones with MI's never have chest pain but will have N/V.

You really have to pay attention to the " little changes" in this group, because they are neither "textbook" or able to tell you whats going on.

Part of the problem is the amount of residents to the nurse in LTC and the ability to spot something is "not quite right", can be difficult. That is why my nursing assistants are so valuable, they know them better and if they tell you something's not right, you better go check.

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txspadequeenRN has 20 years experience as a BSN, RN and specializes in ICU, PICC Nurse, Nursing Supervisor.

4,373 Posts; 29,289 Profile Views

are you writing a essay on this cause these are great questions????

evidence suggests that patients show signs of deterioration up to 8 hours before they actually become unstable and proceed on to cardiac arrest if not treated in that 10 minute window of instability.

how do you know your patient is deteriorating before this period of instability?

what barriers in the workplace and culture inhibit early recognition of deterioration?

thanks for your thoughts.:nurse:

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Blee O'Myacin is a BSN, RN and specializes in ED, ICU, Heme/Onc.

721 Posts; 5,824 Profile Views

Increased anxiety. I don't know my patients before they come in "in trouble", but if I have a wife "scolding" her biligerent husband and telling me "he's NEVER like this, I just don't understand" - then I know something big and bad is on the horizon.

Or just a slow and insidious vital sign change over the course of a shift. Could be something like a SPO2 of 97 at 0800 and then 95 at 1200, and 93 at 1400... etc.

Blee

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mamason has 5 years experience and specializes in cardiac.

555 Posts; 6,708 Profile Views

Vital signs

what they are doing on the heart monitor

I's and O's

O2 sats

lab values- I check these often during the shift

pt's color

pt's preception as to how they feel

new onset of confusion/disorientation

LOC

Any changes that are occuring during your shift.

Sometimes just the slightest change in anything could be an indicator to big things to come.

And intuition. Sometimes you just feel that something's not right.

Hourly rounds are always a good thing to help monitor my patients.

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25 Posts; 2,151 Profile Views

pt's preception as to how they feel

quote]

I think this is great to include. I usually ask this during my initial assessment. It's a simple thing, but some patients will wait until something is seriously wrong before they speak up. So, instead of waiting for them to say something, I think it's smart to ask. When you ask, they're more likely to tell you if something new is happening bc they won't feel like they're complaining.

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jessiern is a BSN, RN and specializes in Med-Surg.

611 Posts; 6,200 Profile Views

Anytime a patient says to me "I just don't feel right" I kinda get a knot in my stomach. Patients get watched very closely and the charts is reveiewed for anything that may have been missed. Even in the short year I have worked, I have had many patients say that to me, and a few hours later they were in trouble-so I do my personal best to get the doc in to see them, and figure out what is happening before its an emergency.

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Antikigirl has 13 years experience as a ASN, RN and specializes in Education, Acute, Med/Surg, Tele, etc.

2,595 Posts; 13,459 Profile Views

Vital signs

what they are doing on the heart monitor

I's and O's

O2 sats

lab values- I check these often during the shift

pt's color

pt's preception as to how they feel

new onset of confusion/disorientation

LOC

Any changes that are occuring during your shift.

Sometimes just the slightest change in anything could be an indicator to big things to come.

And intuition. Sometimes you just feel that something's not right.

Hourly rounds are always a good thing to help monitor my patients.

Excellent and totally utterly agreed!

Another odder one I would add is some people get a wierd feeling...called "impending doom". I hear patients say "I am going to die" and have learned to totally believe they might just and keep a good eye on them! Some people will actually say "I have an impending feeling of doom"...then I know for sure!!!!!! It is wierd I know...but honestly...that too is a sign that has proven correct too many times in my career for comfort!:uhoh21:

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mamason has 5 years experience and specializes in cardiac.

555 Posts; 6,708 Profile Views

Excellent and totally utterly agreed!

Another odder one I would add is some people get a wierd feeling...called "impending doom". I hear patients say "I am going to die" and have learned to totally believe they might just and keep a good eye on them! Some people will actually say "I have an impending feeling of doom"...then I know for sure!!!!!! It is wierd I know...but honestly...that too is a sign that has proven correct too many times in my career for comfort!:uhoh21:

Yep! I hate it when a pt starts talking like that. Huge, huge, huge, RED FLAG!:no:

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284 Posts; 6,644 Profile Views

A patient that has been confused for days and suddenly totally with it. Look out. And of course Vice versa is no good.

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1,348 Posts; 8,536 Profile Views

I think the biggest barrier to recognizing a downward trend is poor staffing and too much work. These days a nurse is lucky sometimes to see a pt on a med/surg unit once every two hours unless that pt is on the call bell all the time. Nurses just do not get to spend enough time with their patients anymore to be able to spot a problem. They don't get to know the pt's habits and what is normal or abnormal for that particular patient.

This is why I think that the Rapid Response Teams here in the US are a crock. We never needed these teams years ago because nurses were able to spend enough time with their patients to catch the subtle hints that something was wrong and disaster was easily averted. Now we have to have them because the JOKO morons say we must have them but the teams still are not averting disaster. They are simply picking up the pieces halfway into the crisis just prior to calling a code. If the staffing and work load had been appropriate, the nurse would have noticed things "weren't quite right" and would have implemented interventions to prevent any problems in the first place.

These days the nurses don't even have time to look back at a vs and I/O sheet to see that things have been looking fishy the last couple of shifts. If they had the time, we wouldn't be having so many problems.

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flightnurse2b is a LPN and specializes in EMS, ER, GI, PCU/Telemetry.

2 Articles; 1,496 Posts; 16,289 Profile Views

anytime a patient is talking to a family member you know is probably deceased, it is never usually good.

i coded a little old man once whose last words were "damn it, loretta!" before he went into a full blown arrest. (his daughter later told me loretta had died 6 months earlier).

ever since then i have to wonder... if they are really confused, or if they know their time is coming to see that family member again very soon.....

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