ABCDE

ABCDE

For the last couple of weeks, I have been reading in preparation for my Acute Illness Management course (Greater Manchester Critical Care Skills Institute, 2014).  I have covered chapters on caring for acutely ill patients who have respiratory problems, hypotension, severe sepsis, a poor urine output, an altered level of consciousness and acute pain.  As well as learning about the specifics of each condition, a common systematic assessment method of ABCDE was applied to each.  Acute illness management is extremely important, because, historically, there have been failures in measuring and recording basic routine observations, in recognising when vital signs get worse, and therefore a delay in responding to deteriorating patients appropriately and timely (National Patient Safety Agency, 2007).

Yesterday, I attended a series of lectures and workshops which related to each of the above conditions and the assessment process in more detail.  An assessment demonstration of a patient was given, followed by a chance to practise, and watch others practising assessment.  Finally, I was individually assessed in carrying out an ABCDE assessment on an acutely ill ‘patient’ mannequin, and also had to take a written test too.  The practical test was extremely nerve-wracking and there was a lot to remember, but fortunately for me, I was able to pass on both of the elements.  Hereby follows an overview of what an ABCDE assessment involves, in order for me to reflect upon and consolidate my learning.

Initially, wherever possible, information on the patient’s situation and background must be handed over to the assessing nurse.  This should include their name, age, what has currently happened to them, and a brief overview of their medical history, including known drug allergies, and previous diagnoses.

AIRWAY: A patient’s airway MUST be patent and maintained before anything else can be done – if the patient cannot get oxygen into their body, they will soon die from hypoxia.  An easy way to check the airway is to speak to the patient, and if they can talk back this is a positive sign.  Thinking about the patient in terms of AVPU – Alert, Voice, Pain or Unresponsive – if the person is in the Pain or Unresponsive stage, their airway is likely to need some assistance, such as an oropharyngeal airway, and may also benefit from repositioning onto their side.

oropharyngeal

Alternatively, the patient may have an obstruction in their mouth and may require some suction.  If there are any noises, such as snoring, crowing, gurgling or stridors, these are likely indicators of an obstruction, while a crackling noise may indicate pulmonary oedema (fluid on the lung).  If a patient has pulmonary oedema, it is important not to give them fluids, as they may drown internally.  A see saw chest and abdomen movement, where the chest moves inwards and the stomach moves out, is likely to indicate a complete airway obstruction.

Once the airway is patent, the patient may require some breathing assistance, and so their oxygen saturations should be checked to determine their O2 levels.  A 15 litres per minute non-rebreather high concentration oxygen mask should be applied, if required.  The bag should be inflated by two-thirds before putting onto patient.  Normal O2 levels are 94-98%, or 88-92% for a person with Chronic Obstructive Pulmonary Disease.

oxygen mask

BREATHING: Once the airway has been properly attended to, the breathing can now be assessed.  Look at the depth, rate and rhythm of the breathing.  Is the respiration in the normal range of 12-20 per minute?  Or is it raised or decreased?  An increased respiratory rate is an early indicator of deterioration, and the patient will soon get tired from continued tachypnoea.  Look for symmetry in the chest movement.  Is the patient struggling to breath and having to use accessory muscles, such as the shoulders?  Consider sitting the patient upright with pillows, as it will be more difficult for them to breath when lying flat on their back.  Look at the patient’s colour, and determine whether it is healthy, pale or cyanosed.  A good indicator of central cyanosis is a blue-tinged tongue, or blueness inside of the lips.  If oxygen has not already been considered, now is an opportunity to determine the oxygen saturations, and to apply a 15 litres per minute high concentration oxygen mask, if required.

CIRCULATION: Once the breathing has been addressed, the circulation can now be assessed.  Starting at the tips of the fingers, check the capillary refill time by depressing the finger tip for 5 seconds.  Does the blood return at a normal rate of about 2 seconds, or is it increased or decreased?  Moving on to the radial pulse (on the wrist), is it in the normal range of about 80-100, or is it raised or slow?  Is the heart rate strong and bounding, or is it weak and thready?  Moving up the arm, is there a wide bore cannula in situ and patent, or does that need to be attended to later?  Does the manual blood pressure fall within the normal range?  120/80 mmHg is ideal, but anything between 90/60 mmHg to 140/90 mmHg may be acceptable (NHS Choices, 2015).  If a patient has baseline measurements, these are really useful for making informed comparisons of what is normal for them.  Do not use electronic dynamap machines when patients are acutely unwell, as they are likely to be inaccurate or will result in an error message.

sphygmomanometer

Moving up to the underarm (axillary), is the patient’s temperature normal, pyrexic or low?  This should ideally be about 36.5˚C.  Moving across and down to the stomach area, consider whether the patient has a normal urine output, or is there no information on this?  A normal output is about 0.5 ml/kg/per hour, so should therefore be about 35 ml for a 70 kg patient.  Consider putting the patient onto a fluid balance chart for monitoring.  If the heart rate is higher than the blood pressure, consider giving fluids to rectify the readings.  250 ml of 0.9% sodium chloride IV over 5-10 minutes is standard.  Once the fluid is administered, any changes in pulse and blood pressure should be reassessed, and then another 250 ml can be given, if necessary.  Once all the circulation checks are complete, bloods can be taken from the cannula site, and should generally include a Full Blood Count, Urea and Electrolytes, INR for clotting and Glucose.  If the patient has a high temperature, blood cultures should be taken to check for sepsis infection, and in the case of sepsis, IV antibiotics would need to be administered too.  Once the bloods are obtained, the IV fluid or antibiotics can then be administered via the site.

blood tubes

saline

*****Throughout the whole assessment process, it is important to keep going back to check on the previous stages.  For example, if an oropharyngeal airway was used in an unconscious patient to maintain the airway, and the patient becomes conscious, the airway adjunct will need to be removed.  If the patient is using an oxygen mask however, this should be kept on until the doctor arrives; although oxygen saturations should be periodically checked.

DISABILITY: An excellent mnemonic to remember this stage is GAPPS. G – Glucose – does the patient have normal blood glucose readings between 4-7 mmol/l, or are they presenting as hypo or hyper-glycaemic?  If hypoglycaemic, IV dextrose will be required.  If hyperglycaemic, insulin will be required, although this would need prescribing by a doctor.  A is AVPU – Alert, Voice, Pain, Unresponsive – how is the patient doing? Are there any improvements?

AVPU

P – Pupils – when a light is shined in a sweeping moment across each eye, do the pupils constrict ordinarily in reaction to the light, or are they dilated and possibly indicative of drugs?  Does one pupil constrict and the other dilate?  Unilateral responses could be a sign of neurological injury (Patient, 2015).

pupil light pen

P is also for pain.  Is there any indication of pain in the patient?  If so, a doctor will need to prescribe an appropriate level of pain relief.  Finally, S is for seizures.  Has the patient had any seizures?  If they are prolonged or recurrent, the usual treatment is rectal diazepam (Epilepsy Action, 2015).

WHO analgesic ladder

EXPOSURE: The physical assessment concludes with a head to toe examination of the patient, front and back, in order to ensure that nothing abnormal has been missed, such as wounds/trauma, rashes, swelling or dryness.  Once this is finished, it is important to go back to the earlier stages again, and make sure that everything is stable or improving.

Once the doctor arrives, it is essential that the assessing nurse hands over the full information of what has been done, including the patient’s initial presentation and background, the assessment findings, and any actions taken.  The nurse needs to ask the doctor for a management plan and also for further prescriptions of oxygen, fluid, pain relief, insulin, etc.  A useful tool for communicating information accurately is the SBAR model – Situation, Background, Assessment and Recommendations.

SBAR

References and Further Reading

Epilepsy Action. (2015). Status epilepticus. Retrieved 21st November, 2015, from https://www.epilepsy.org.uk/info/treatment/status-epilepticus

Greater Manchester Critical Care Skills Institute. (2014). Acute Illness Management (5th ed.). Greater Manchester: Critical Care Skills Institute.

National Patient Safety Agency. (2007). Safer care for the acutely ill patient: learning from serious incidents. Retrieved from http://www.nrls.npsa.nhs.uk/resources/?EntryId45=59828

NHS Choices. (2015). Your NHS health check results. Retrieved 21st November, 2015, from http://www.nhs.uk/Conditions/nhs-health-check/Pages/Understanding-your-NHS-Health-Check-results.aspx

Patient. (2015). Pupillary abnormalities. Retrieved 21st November, 2015, from http://patient.info/doctor/pupillary-abnormalities

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Stress Revision

I continue to be extremely busy on placement within the community, working alongside the Home-Based Treatment Team (formerly called the Crisis Team). This week I also spent two days with the Rapid Assessment Team at two separate local hospitals. The teams deal with mentally ill people who present at Accident and Emergency, and also assess patients who are in hospital already (usually with physical problems), but are also presenting with signs of possible mental illness. Many of the A & E attendees are referred to the Home-Based Treatment Team where I am presently working, and the people are then supported in the community through daily home visits.

a & e

Aside from this, I am still busy revising for my forthcoming exam which takes place towards the end of September. At the moment I am revising stress, and in order to help me clarify my learning (like last week with the diabetes topic), I thought that I would try to rewrite some of the main facts that I have learnt.

Long-term Stress and the Effects upon the Body

Short-term positive stress, sometimes known as eustress, can be beneficial, and can help us to achieve things, such as passing an exam! Long term stress, in contrast, is negative and distressing to the individual’s body and their mind.

Short-term stress can produce temporary beneficial changes, such as raised blood pressure and raised blood glucose, and the body’s homeostasis is quickly regained. Long term stress also produces the same increases, as well as a weakened immune system. The body’s homeostatic levels however, are eventually re-set at a much higher level, and the resulting consequences can sometimes be serious illness, such as myocardial infarction and cancers.

When faced with stressful circumstances, the brain’s hypothalamus causes the body to go into fight or flight mode. This stimulates the sympathetic branch of the autonomic nervous system, which then stimulates the adrenal medulla to release adrenaline. The adrenaline causes the heart rate to increase and the blood pressure goes up. If the stress is short-lived, as in healthy individuals, the parasympathetic branch of the autonomic nervous system will eventually take over, and a state of relaxation and calm will once again return. In long-term stress however, the heightened, and potentially damaging, effects of the sympathetic branch are maintained by the release of several hormones.

fight or flight

Stimulated by the hypothalamus, Corticotrophin Releasing Hormone (CRH) stimulates the production of cortisol, which leads to loss of appetite and loss of libido. It also causes a reduction in the immune system, the slow healing of wounds, muscle wastage, loss of bone mass and the breakdown of glycogen to glucose, thus increasing blood glucose levels. The CRH also stimulates the release of AdrenoCorticoTrophic Hormone (ACTH). ACTH stimulates the adrenal medulla to produce aldosterone and cortisol. The aldosterone stimulates the kidneys to retain sodium, which then attracts water, and so the blood volume and blood pressure therefore increase. High blood pressure (hypertension) is associated with problems such as stroke, heart disease and diabetes. Growth Hormone is also released, and this breaks down fat and converts glycogen to glucose. Thyroid Hormone is additionally released, and this stimulates Thyroid Stimulating Hormone (TSH). TSH increases the speed of all bodily reactions, including the metabolic rate, thus increasing the chances of weight loss.

blood pressure

Stressed individuals frequently experience poor sleep, and this inability to rest and recuperate, sadly and ironically, enhances the stresses. Negative coping strategies such as alcohol and drug misuse can make the problem worse, as can poor diet and lack of exercise. Sleep, when achieved, stimulates the parasympathetic branch of the autonomic nervous system, which in turn reduces the adrenaline. Sleep is therefore a great healer in recovering from stress.

Lack of sleep and stress can be antecedents to anxiety and depression. Concentration is diminished or lost, and the small things in life can soon start to feel like huge mountains. Other complications of stress can be migraine, Irritable Bowel Syndrome, ulcers and gastritis.

snoopy sleeping

Needless to say, stress is not good for our working lives either. The Health and Safety Executive (2012) stated that 10.4 million working days were lost through stress, while the Labour Force Survey (2012) found that females generally experienced higher working stress, and that the age group of 35–44 had the highest amounts of individuals affected. This could perhaps be on account of the females’ additional responsibilities such as children, household chores, and possibly caring for elderly parents.

Stress is clearly a potentially negative force, and one that can damage both our bodies and our minds.

My final week with the Community Mental Health Team

Tomorrow will be my last day with the Community Mental Health Team, as my four week placement has now reached its end.   This learning curve has been fabulous, but it is now time to return to my studies at university. 

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This week I attended the Clozaril Clinic, in which clients who are taking the anti-psychotic drug, Clozapine, regularly have their blood taken for monitoring of their white blood cell count.  As a result of taking the drug, clients are at risk of developing neutropenia or agranulocytosis.  This is when the white blood cell count gets low, and the person’s immune system consequently becomes compromised.   In order for clients to remain healthy, it is therefore essential that those taking Clozapine regularly attend for testing. 

In the first 18 weeks of starting Clozapine, clients should be tested every week, and then every fortnight for up to a year.  Afterwards a monthly test is the usual requirement.  The results of the blood tests are carefully scrutinised, and are awarded a rating of green, amber or red.  A green result is absolutely fine, whereas a red result means that the medication should be stopped with immediate effect.  An amber result will require another blood sample to be taken, and depending on the result, a decision will be made to either stop or continue with the medication. 

Clients on Clozapine have to tolerate regular blood monitoring, because of the strong possibility of undesirable side-effects being present.  These clients will be taking Clozapine specifically because other anti-psychotics have not suited them.  Clozapine is one of the old atypical drugs, but it is still the best choice for a significant number of clients.  The drug, Lithium, as commonly taken by clients who are bi-polar or manic depressive, is another medication where regular blood monitoring is an essential requirement.  Regular Lithium clinics are also therefore held at the Community Mental Health Centre.

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On another day this week, I went with the Occupational Therapist to take a lady shopping.  The client has learning disabilities and is currently being assessed to determine her levels of independence and need.  The shopping trip was to the local supermarket, which also has a clothes section.  The client, the OT and my-self walked from the client’s place of residence to the shop.  Along the way, the client was regularly observed to see how she coped with using the pedestrian crossings and negotiated general road-crossings. 

At the shop, the client found that she had forgotten to bring her shopping list, but she was still fortunately able to remember what she needed to buy.  The client chose some items of clothing and was aware of her size requirements.  I helped her to find the correct sizes and she was reminded to keep her receipt, just in case later, they are found not to fit properly.  The client also bought a few essential toiletries and then made her way to the till point, in order to pay.  The OT carefully observed to see how she managed her handling of cash, and she did fairly well, except for not checking her change. 

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It was lovely to walk back with the lady and help her to negotiate the road-crossings once again.  I was rather touched that she chose to link my arm and chatted to me a little as we made our way back to her home.  Upon arriving, the OT reminded her to hold on to her receipt for the clothes items, just in case they needed to be changed.  It was lovely to have done something useful, in order to have helped a person in need of some assistance.  Upon arriving back at the office, the OT and my-self filled in the assessment form of how the client had coped with different aspects of the shopping trip and traffic awareness.  On the whole, she had done rather well.

Working with the Community Mental Health Team

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My second week in the community is now complete, and I am now half way through this short placement of just four weeks.  It is a great shame that this placement is not actually the longer one of ten weeks, which is later in the year, as I absolutely love it and the time is going far too quick.

As being a community mental health nurse is rather like being a social worker too, the role is sufficiently varied to keep it interesting and challenging.  Part of the time is spent in client’s homes, maybe delivering a specific talking intervention over a cup of coffee, giving them their two-weekly depot injection, or just making sure that everything is generally okay with them. 

Another part of the time is spent seeing clients at the mental health centre.  Clients may be visiting to have their depot injection or to get their bloods checked, or they may be attending for a six or twelve monthly review of their treatment.  If it is the latter, the resulting paperwork is extensive.  The review has to be written up, and copies are sent to the client and their GP.  The client’s risk assessment and care plan are updated, and an essential care cluster review and a SALT are carried out.  I can’t remember what SALT stands for, but I know it is not the acronym that I am usually familiar with – speech and language therapist – and is instead something to do with the social work side of assessments.  Of course, if clients have got better and have stabilised, reviews sometimes end in them being discharged from the service.  It must be so rewarding for the staff to see a previously poorly client regain good mental health once more.  It can often be a long journey, and this is what must make it all the more worthwhile.

As inferred above, another part of the time is spent in the community mental health office, catching up with all the paperwork.  After a couple of client visits, this does tend to pile up rather quickly, and I can see that if you are not very careful, paperwork could potentially take over from actual client contact.  It is therefore essential to be organised and to get ahead as much as you can.

Yet another portion of the time is spent being on duty triage.  Unwell clients or concerned family members phone up for advice, and if a person is deemed to be in need of further help, they may be asked to visit the community mental health centre, in order to have an assessment.  The assessment may be booked for a future date, but if really urgent, will be carried out that day.  Assessments are a hugely time consuming exercise, but are essential for nurses to get to know their clients, what might be wrong with them, and how they can be helped.

I took the notes during an assessment last week, and it took about two hours in total.  Information needed to be gathered under various headings, such as presenting problem, past psychiatric and physical health history, medication, family history, personal and social history, appearance and behaviour, speech, mood, and so forth.  The resulting array of information was massive, and of course, all had to be typed up once the exercise was completed. 

The process that I witnessed was not just an information gathering procedure.  The community psychiatric nurse, that conducted the assessment, spent time to build a good rapport with the client, and used appropriate opportunities to teach the client about the identified problem, and to persuade them to see how the likely diagnosis was justifiably applicable.  The nurse was extremely skilful and managed to normalise some of the client’s concerns by sharing a little about her own personal life experiences.  This shared human element was extremely effective, and helped to put the client at ease, and to help the client to address the next stage of her treatment journey.

The experience with the community team is proving to be both enjoyable and educational.  I can hardly wait for week three to begin, but for now I will enjoy what is left of the weekend.