This document provides guidance on systematically assessing patients for early signs of critical illness deterioration. It outlines the steps of the ABCDE approach to assessment, including airway, breathing, circulation, disability, and exposure. Specific signs and symptoms to evaluate for each system are described. The document also discusses appropriate oxygen delivery systems and when to call for help. SBAR is introduced as a standardized communication structure for requesting assistance or escalating care.

1. May 09 F2's
Early Warning Signs and
Symptoms of Critical Illness
& Systematic Patient Assessment
Shibu Chacko
Critical Care Outreach

2. Critical Care Team
how and when to refer

3. If not done, what happens?

4. What are we trying to stop?
PATIENT DETERIORATIONPATIENT DETERIORATION
Recognise the signs & symptoms
of critical illness

5. Poor management of what/
signs & symptoms from where?
Airway
Breathing
Circulation
Oxygen therapy
Monitoring
PATIENT DETERIORATIONPATIENT DETERIORATION

6. Utilise basic
examination skills
 Look
 Listen
 Feel
 Airway
 Breathing
 Circulation
 Disability
 Examination
Do not progress from A to E until each stage completed

7. Assessing the Patient : Airway
Upper airway obstruction
complete or partial? How do you know
Chin lift,head tilt
Protect c spine
Suction
Airway adjuncts
+
Do you need help now ?

8. A = Airway
 Is it clear & patent?
 Can the patient talk?
 Is the patient unconscious?
 Do they need their airway
protecting?
 Is there a possibility of spine
injury?
 Can you remove the obstruction?

9. Protecting the Airway
 Airway adjuncts can be used to help
maintain an airway of an unconscious
patient.
An oropharyngeal (Guerdal’s) airway
Nasopharyngeal airway
Tracheal Intubation (gold standard)
 What would dictate which you would
use?
 How would you size them?

10. Assessing the Patient : Breathing
•Rate
•Rhythm
•Depth
•Symmetry
•Colour
•O2 sats
Do you need help now ?
What is normal?

11. Oxygen Delivery Systems??

12. Nasal Cannula
Simple Face Mask
Fixed Concentration Mask (Venturi System)
Quattro Humidification System
Non-Rebreather Mask & Bag (High Concentration Mask)
•Uncontrolled Oxygen Delivery System
•Flow Rate: 0.5 – 4 lpm (litres per minute)
•Suitability: All patients who require low flow oxygen therapy
•Uncontrolled Oxygen Delivery System
•Flow Rate: Minimum 5 lpm (litres per minute)
•Suitability: General purpose
•Controlled Oxygen Delivery System
•Flow Rate: Indicated on each venturi (different colours for different O2 %)
•Should be the system of choice
•Controlled Oxygen Delivery System
•Flow Rate: Indicated for each oxygen percentage
•System of choice for patients requiring oxygen for 6 hours (excluding nasal cannulae)
•Uncontrolled Oxygen Delivery System
•Flow Rate: Minimum 10 lpm, Maximum 15 lpm (litres per minute)
•System of choice for acutely unwell patients
January 2006 Catherine Plowright, Nurse Consultant Critical Care. Jane Kindred, Respiratory Nurse. Zoe Dennett, Critical Care Educator.
Oxygen Delivery Systems

13. Why oxygen??
 All patients undergoing resuscitation for
whatever reason will have some degree of
hypoxia.
 How much?
As much as you possible – aim for >85%
 Are there any exceptions?
No – even pts with chronic lung disease
are hypoxic at the time of resuscitation.
CO2 kills slowly but no O2 kills quickly.

14. Assessing the Patient: Cardiovascular
•Capillary refill time
•Limb temperature
•Peripheral pulses
•Central pulses
•BP
•Heart rate & rhythm
•O2 saturation
•Urine output
Do you need help now ?
What is normal?

15. What are you going to do??

16. Assessing the Patient: Disability
• AVPU
 A – Alert
 V – Responds to voice
 P – Responds to pain
 U - Unresponsive

17. D = Disability & Pain
Disability (neurological) & Pain
What is your patients
GCS/AVPU?
Are they verbalising
appropriately?
What is their pain score?

18. Assessing the Patient: Disability
•AVPU
•Pupils
•Blood glucose
Recovery
position
Do you need help now ?
What is normal?

19. Assessing the Patient : Exposure
Examination vs Environment
Consider
Hypothermia
&
Dignity

20. Checklist!!!!
 Who would you call for help?
 Why would you call for help?
 What help would you expect?
 Where would this help come from?
 When should it be called for?

22. SBAR
 The SBAR (Situation-Background-
Assessment-Recommendation) technique is a
communication tool designed to be used
between members of the healthcare team
about a patient’s condition.
 It allows all staff an easy and focused way
to set expectations for what will be
communicated and to ensure they get a
timely and appropriate response.

23. What it is not?
 It is not to be used to call for
emergency e.g.
 Unconscious patient
 Cardiac arrest
 Any other medical emergency
 You must then call 2222

24. For all communication situations
 CSW to RN
 CSW to Outreach
 RN to Outreach
 RN to doctor
 Doctor to Doctor

25. SBAR – Situation
(NB will depend on level of competence):
 Identify yourself, unit, patient, ward
 Briefly state the problem, what is it,
when it happened or started, and
how severe

26. "This is Lou, a registered nurse on
Nightingale Ward. The reason I'm
calling is that Mrs Taylor in room 225
has become suddenly short of breath,
her oxygen saturation has dropped to
88 per cent on room air, her
respiration rate is 24 per minute, her
heart rate is 110 and her blood
pressure is 85/50.”

27. SBAR – Background
(NB will depend on level of competence):
 Pertinent background information
related to the situation
 Most recent observations & MMEWS
 Other clinical information

28. "Mrs. Taylor is a 69-year-old
woman who was admitted from
home three days ago with a
community acquired chest
infection. She has been on
intravenous antibiotics and
appeared, until now, to be doing
well. She is normally fit and well
and independent.”

29. SBAR – Assessment
(NB will depend on level of competence):
 What do you think is going on, what
is your clinical opinion?
 What is your request or
recommended action, and when is it
required?

30. "Mrs. Taylor’s observations have been
stable from admission but deteriorated
suddenly. She is also complaining of
chest pain and there appears to be
blood in her sputum. She has not been
receiving any venous
thromboembolism prophylaxis.”
“I’m not sure what the problem is, but I am worried.”

31. SBAR – Recommendation
(NB will depend on your level of competence):
 Explain what you need - be specific
about request and time frame
 Make suggestions
 Clarify expectations
 Finally, what is your
recommendation? That is, what
would you like to happen by the end
of the conversation with the health
care professional you are speaking
to?

32. "Would you like me organise a
CXR? and ABGs? Start an IV
fluid?
I would like you to come
immediately”

34. Useful reading
 Anderson ID (ed) 2003 Care of the Critically Ill Patient 2nd
ed Arnold London
 McQuillan P et al 1998 Confidential inquiry into quality of
care before admission to intensive care British Journal of
Medicine 316:1853-1858
 NCEPOD 2005 An Acute Problem? www.ncepod.org.uk
 Smith G 2003 ALERT manual 2nd
ed University of
Portsmouth
 Etc etc etc