NSE 203 Final Review (2023/2024) Rated A+

NSE 203 Final Review (2023/2024) Rated A+ clinical deterioration not promptly recognized can increase pt morbidity & mortality barrier to recognizing & responding to clinical deterioration stems from ... practice variations among HCP consequences of not recognizing patient deterioration increased mortality, resuscitation, implementation of higher lvl of care & prolonged hospital admission What is part of an ABCDE assessment? 1) airway 2) breathing 3) circulation 4) disability 5) environment & exposure priority things to look for in pt airway? - any blocked or threatened airways - pt LOC - abnormal respiratory assessment findings (ex; stridor) if you suspect neurological trauma when assessing airway you ... start w/ triple airway maneuver!! Triple airway manoeuvre chin lift, jaw thrust, patient oxygen what does vital sign instability & visible patient deterioration tend to occur? in most pts from 6-24 hrs before cardiac arrest clinical deterioration patient compromising *hemodynamic stability, marked by physiological decompensation* accompanied by subjective or objective findings. dynamic state variations in physiological parameters decompensation inability to maintain homeostatic fxn physiologically or psychologically what are indicators of clinical deterioration - sudden and/or unstable changes in vital signs (RR, BP, HR, O2) - for expert nurses, their intuition helps them determine if a patient looks right - skin color changes - decreased LOC assessments to recognize deterioration ABCDE NEWS2 FAST signs during primary survey that are *significantly associated w/ death* ... - partial airway obstruction - poor peripheral circulation - greater than expected drain fluid loss - decreased UO - decreased GCS - abnormal RR - new pain - low O2sat & low BP - alteration in mentation NEWS2 aka national early warning score purpose of NEWS2 - improve detection of & response to clinical deterioration in patients w/ acute illness - provide *standardized approach* to care of deteriorating patient - clear communication - identify a *score* for urgent clinical response what does the NEWS2 score mean? *a high NEWS2 score* identifies a sick patient who is deteriorating & requires *urgent clinical review* what does NEWS2 score evaluate? - RR - O2 Sat - systolic BP - HR - LOC or new confusion - temp what to do if NEWS score is greater or equal to 3 discuss w/ duty nurse/senior colleague, & complete a *sepsis screen for signs of infection* what to do if NEWS score is greater or equal to 6 immediate