Immediate management for all unwell patients
From WardWiki - Foundation Doctor Helper
Situations can develop and deteriorate very quickly on wards where conflicting interests, distractions and paucity of skilled labour conspire against optimal health care delivery. It is imperative that over enthusiasm is tempered by efficiency and sagacity and each ill patient must be approached with both care and attention. It is dangerous to patients and personally distressing when important steps are missed. Rushed unfocussed assessments where the desire to have the diagnosis proven correct overwhelms, or excessive zeal over certain tasks leads to neglect of others is all too common and hard to acknowledge.
Wardwiki makes no apology for repeating the following mantra, based in large part on ALS, ATLS, Ccrisp and other courses, that it be acted on before further investigation can follow.
Immediate management for all unwell patients
Assess the patency and protection of the airway. Take baseline observations, viewing them on a chart using an early warning system.
If evidence of airway compromise, contact anaesthetist and your senior colleague. If there is a raised or reduced respiratory rate, listen to the chest and give high flow oxygen via a non-rebreathe mask
If there is a tachycardia, low blood pressure or evidence of dehydration establish IV access and give a fluid challenge. See NICE guidelines on fluid challenges Consider now placing a urinary catheter. Send off FBC, U&E, CRP, Group and Save, and any special relevant blood tests
If there is pyrexia equal to or above 38 or less than or equal to 35 degrees, take blood cultures. If SIRS is confirmed or sepsis suspected consider the Severe Sepsis Resuscitation Bundle. If patient meets these criteria and does not respond well to initial management contact a senior team member, and a member of critical care who can see the patient or give advice immediately.
Always cross match at least two units for a patient in extremis. It is time consuming and distressing to attempt(pointlessly so) to rush the blood bank to dispense blood later on.
Note a urinary catheter is therapeutic only in cases where an empty bladder is desired (including transfer to theatre for surgery). It is important not to miss out resuscitation and diagnostics steps in the first hour in an effort to set up equipment that measures a patient only hourly. Your initial fluid challenges will, by definition, not be affected by your promptly placed urinary catheter.
