VITAL SIGNS
VITAL SIGNS:
What vital sign is typically the first to change in a declining patient?
Respiratory rate is typically the first vital sign to change in a declining patient.
ASSESSMENT:
What type of assessment do you complete upon admission or initiation of care? Why is this important?
Complete head to toe assessment: This comprehensive assessment is usually conducted upon admission or initiation of care to create a thorough baseline assessment for the patient.
INTERVENTIONS:
What are expected interventions for a declining patient who’s respiratory system is affected?
Maintain airway, administer oxygen, raise the head of the bed if indicated, ensure suction is available, continually assess vital signs, continuous pulse oximetry and end tidal carbon dioxide monitoring, blood gases, applicable labs
COMMUNICATION:
What communication tool is used to provide a structured handoff report?
SBAR (situation, background, assessment, recommendation)
PATIENT EDUCATION
What are 2 methods of education delivery for patient and families?
One-on-one, written, return demonstration, education materials, demonstration and videos
VITAL SIGNS:
Define the term “tachypnea” and its significance in assessing a declining patient.
Tachypnea refers to an abnormally rapid respiratory rate, typically exceeding the normal range for age and activity level.
ASSESSMENT:
What type of assessment would you complete once you recognize a health issue?
Problem-focused assessments are most often the next step following recognition of a health issue.
INTERVENTIONS:
What are expected interventions for a declining patient who’s cardiovascular system is affected?
12-lead echocardiogram (EKG), assessment for dysrhythmias, chest pain or shortness of breath, monitor electrolytes, continuous vital signs and cardiac monitoring, lab work, administer medications per policy
COMMUNICATIONS
What are the 5 components of comprehensive documentation?
•Subjective data: Information provided by the patient or caregiver, including chief complaint, medical history and subjective symptoms.
·Objective data: Measurable and observable findings obtained through physical assessments, vital signs, diagnostic tests and observations.
·Assessment: Nurses’ interpretation of the patient’s condition based on subjective and objective data.
·Plan of care: Intervention planned or implemented to address the patient’s needs, including medication, treatments and patient education.
·Evaluation: Documentation of the patient’s response to interventions and outcomes achieved.
·Education
PATIENT EDUCATION
List 2 reasons why patient and family education matters.
Improves patient outcomes, enhances communication with healthcare providers, promotes shared decision-making, empowers family members to advocate for patient’s needs and preferences.
VITAL SIGNS:
Describe how to measure respiratory rate accurately in a patient.
To measure respiratory rate accurately, observe the patient's chest rise and fall for one minute while they are at rest and not aware that their breathing is being monitored. Alternatively, count the number of breaths in 30 seconds and multiply by 2
ASSESSMENT:
What specific clinical tool is commonly used to assess a patient’s level of consciousness and neurological status in the context of declining health?
Glasgow Coma Scale
INTERVENTIONS:
What are expected interventions for a declining patient who’s neurological system is affected?
Neurological: Maintain airway, monitor for changes in level of consciousness, frequent neurological exams, continually assess vital signs, blood glucose, stroke or seizure protocols if applicable
COMMUNICATION
This communication technique involves active listening, validation and empathetic response to a patient’s expressed feelings and concerns.
Therapeutic communication
PATIENT EDUCATION
This term refers to a healthcare professional whospecializes in proving emotional support, education and resources to patients and families facing serious illness or medical crisis.
Medical social worker or palliative care specialists
VITAL SIGNS:
What is the normal range for systolic blood pressure and how does hypotension indicate a patient’s decline?
The normal range for systolic blood pressure is typically considered to be 80-120 mmHg.
ASSESSMENT:
What is a key observation when assessing the onset of pain in a declining patient?
A key consideration when assessing the onset of pain in a declining patient is its temporal pattern.
INTERVENTIONS:
What are expected interventions for a declining patient who’s psychosocial system is affected?
Assess for signs of agitation, aggression or self-harm, ensure safety, implementing de-escalation techniques, administering medications per policy
COMMUNICATION
This documentation term refers to the act of recording data or information in a patient’s medical record at the time it occurs.
Real-time documentation
PATIENT EDUCATION
Name 5 key topics to educate patient and family members about during a declining patient event.
Signs and symptoms of decline, early recognition, strategies for patient comfort and safety, goals of treatment, support services, advance directives, resuscitation preferences, end-of-life preferences
VITAL SIGNS:
How does an elevated heart rate (tachycardia) indicatepotential deterioration in a patient’s condition?
An elevated heart rate, or tachycardia, may indicate potential deterioration in a patient's condition as it can reflect various physiological stressors such as pain, hypovolemia, hypoxia, fever, or cardiovascular dysfunction.
ASSESSMENT:
In the ABCDE assessment for a declining patient, what does the “D” stand for?
Disability. The ABCDE assessment is a systematic approach used by healthcare providers to quickly identify and address life-threatening issues in a declining patient.
INTERVENTIONS:
What are expected interventions for a declining obstetric patient?
Maintain airway, continually assess vital signs, continuous pulse oximetry and fetal monitoring, oxygen if applicable, anticipate expedited delivery, maintain IV infusion through large bore IV, begin treatment protocols per policy if applicable
COMMUNICATION
What are the 3 key points a nurse should remember when documenting?
Timely documentation (documentation of event should occur as quickly as possible), Legal, regulatory and professional standards should be followed, Accurate documentation.
PATIENT EDUCATION
Name 3 key components of advance case planning that patients and families should consider when preparing for potential decline in health.
Advance directives, healthcare proxy or durable power of attorney and goals of care