One of the things that I am passionate about is proper patient observation. Not only is it beneficial for the patient, it is useful for the nurse as it gives you a baseline for further evaluation, and gives some quantitative data about the status of your patient.
In one report on patient observation it is stated that ‘patient deterioration is often beautifully documented’ and this is because observations are often recorded with no awareness as to their significance. Respiratory rate is usually the first indication that there is something wrong with the patient, but annoyingly it is rarely documented, even more rarely charted, yet it is one of the easiest observations to record as it requires no special equipment.
This ties very well with World Sepsis day as before you can treat sepsis you need to recognise it.
Sepsis is a medical emergency, and should be treated as such (immediate medical review or 999).
The signs are
- Systolic bp <90mmHG or >50mmHg below normal
- Temperature >38.0ºC or <36.0ºC
- Heart rate >125/min
- Respiratory rate > 25/min
- Altered mental status
- Urine <0.5mls/kg for 2 hours
- Lactate > 4.0
- pH <7.25
- Potential Neutropaenia
There are also a Sepsis 6 App for iOS
Lastly a story to demonstrate the importance of observations.
It was a very snowy february evening. I had been referred a patient for a simple dressing change, so i went to find the patient who had a recent operation, she had a leaking wound site that was looking red and angry. Observations indicated an infection with raised temperature, raised pulse, and low BP. The out of hours GP service was contacted and i was waiting for a call back.
The patient had been experiencing pain, but while waiting for a call back they complained of some more pain and then not feeling well. Observations were re-recorded – temperature had increased, pulse had increased (and become noticeably weaker), and her BP had dropped. Through just these basic assessments i had determined that they had
- A condition which was resulting in deterioration (First observation compared with second)
- They were now showing signs of sepsis
From this i was able to confidently call 999 and request an ambulance. A car attended, handover was given on the walk from the car to the front door (5 meters) and on this basis transport to hospital was requested before the patient had been seen.