You should always work within the expected parameters of your role and capability and know that you are supported by your employer to do so.
Introduction
This guidance highlights the essential skills and actions to respond to and care for people, living in care homes or their own home, who have acute care needs due to COVID-19.
This is an incredibly difficult time for social service workers and keeping up to date with and following COVID-19 information and guidance is physically and emotionally demanding. We know you have a sense of responsibility to provide the highest quality of person-centred care and support. You will be taking the necessary precautions to ensure the safety and wellbeing of yourself and others, while not wanting to cause any additional distress for the people you care for.
We know the skilled care and compassion you provide means so much to those you care for and their families. It is important to remember to keep yourself safe and well. Remember that you also have valuable existing skills and knowledge to help you adapt to some of the changes required during the COVID-19 pandemic.
This guidance will help you work safely and confidently in recognising when someone may be deteriorating and in need of acute care as a consequence of COVID-19.
It is important that you have confirmation from your employer that you are skilled and supported to carry out the tasks asked of you within the parameters of your role. Your employer’s responsibilities are detailed in the Code of Practice for Employers.
If you are at any time unsure of what to do when caring for someone who is acutely unwell, you should speak with your supervisor or manager at the earliest opportunity so that there is a clear understanding of what is expected of you and what steps to take. There may be different expectations regarding your care role if you are supporting someone who is unwell in their own home.
This guide has been developed in partnership by NHS Education for Scotland and the Scottish Social Services Council.
Deterioration
It is important you know how to recognise an unwell and deteriorating person and report/ escalate concerns.
In general, most people infected with COVID-19 will present with mild to moderate symptoms. However, some people are more at risk than others of becoming unwell very quickly and developing a serious illness. This is known as deterioration. As you care for individuals who are at risk of deterioration it’s important you know how to spot the signs.
Remember, if you are at any time unsure of what to do when caring for someone who is acutely unwell, you should speak with your supervisor or manager at the earliest opportunity so that there is a clear understanding of what is expected of you and what steps to take.
Click on each category to learn more.
Sometimes you will notice that someone is unwell, for example if they are more breathless or confused. Other times it may be harder to spot.
If you have cared for a person and know them well it can be a generalised feeling that they ‘are not themselves’ or ‘just don’t seem right’.
Here are some things you should look out for.
Start by asking how they are today to get a sense of how they are responding to you. Do they show any of the following soft signs (subtle observational signs) of becoming unwell/ deterioration?
Increasing breathlessness or coughing.
Change in usual drinking/ diet habits.
A shivery fever – feel hot or cold to touch.
Reduced mobility – ’off their legs’/ less coordinated.
New or increased confusion/ agitation/ anxiety/ pain.
Changes to usual level of alertness/ consciousness/ sleeping more or less.
Can’t pass or difficulty passing urine or change in colour of urine.
Diarrhoea, vomiting, dehydration.
Any concerns from the resident, family or carers that the person is not as well as normal or just not their usual self, similar to those described above.
You can learn more about recognising these soft signs by watching this short video.
Soft signs of deterioration
People who are deteriorating may only display some of these signs, not necessarily all of them, and it’s essential that you report any concerns to your supervisor or manager. If the person shows any of the signs above, you need to take immediate action.
You need to:
raise the alert to a senior care worker, supervisor, registered nurse or manager
carry out an immediate assessment as outlined below, if this is within the parameters of your role.
The purpose of the immediate assessment is to identify any potentially life-threatening problems, call for appropriate help and initiate management to keep the person safe while waiting for help.
If you are unsure or unable to assess a person who may be deteriorating, you must get help to do so as quickly as possible.
It is important that you do this in a systematic way and know how to communicate what you find clearly and effectively. The commonly used system is the ABCDE approach.
First steps
Ensure personal safety including performing hand hygiene and use of appropriate personal protective equipment (PPE) according to current/ local guidelines. You should keep up to date with current Health Protection Scotland guidelines.
If the person appears unconscious or has collapsed, shake them gently via the shoulders and ask ‘Are you alright?’
If the person responds as they normally would, then you can assume that the person has a patent/ open airway, is breathing and has adequate blood supply to the brain. Failure to respond is a sign of critical illness.
Is this a cardiac arrest?
The first step is to decide whether this is a cardiac arrest:
if the person is unconscious, look listen and feel for normal breathing (occasional gasps are not normal)
implement emergency procedures according to policy and the individual’s Anticipatory Care Plan.
If this is not a cardiac arrest, proceed to an ABCDE Assessment.
ABCDE Assessment
You should always work within your capability and the parameters of your role. If you are not sure seek advice and support from other team members and your supervisor or manager.
Always follow your organisation’s policies and procedures on recording and reporting.
A is for Airway
Look for the signs of airway obstruction (blockage):
if the person is talking, or responds in a normal voice, and in normal sentences, then the airway is open (not blocked)
signs of a partially obstructed airway include a changed voice, being able to speak only in phrases or words, noisy breathing, and an increased breathing effort
with a completely obstructed airway, there is no breathing despite great effort
a reduced level of consciousness is a common cause of airway obstruction, partial or complete
treat airway obstruction as a medical emergency and get expert help immediately.
B is for Breathing
Is their breathing noisy, is it difficult to hear, can they speak?
Does their breathing look laboured (difficult)?
How many breaths per minute are they taking?
Check respiratory rate if you are capable of doing so.
Is their breathing regular or not?
Is the person on oxygen? If so, check oxygen saturations (oxygen levels in the blood) if you are capable of doing so and if the equipment is available.
C is for Circulation
Look at the colour of the hands and fingertips: are they blue, pink, pale or mottled?
Assess the limb temperature by feeling the person’s hands – are they cool or warm?
Count the person’s pulse rate if you are capable of doing so.
Check the person’s blood pressure if you are capable of doing so.
Check their temperature if you are capable of doing so.
A rapid or increasing pulse rate, as well as changes in skin colour, sweating, and a decreased level of consciousness are all signs of insufficient circulation.
D is for Disability
In the context of this ABCDE assessment, disability means how alert they are and any other ‘conditions’ they may have.
What is their level of consciousness?
is the person responding to your voice and able to answer you?
are you able to understand what they are saying, if not, is this new?
are they difficult to rouse/ awaken?
are they confused, if yes, is this new?
Is the person known to be diabetic, are they confused? Check blood sugar if you are capable of doing so, even if the person is not known to be diabetic.
Are there any obvious signs of injury, for example blood loss?
E is for Exposure
To examine the person more fully, exposure of the body may be necessary. This would normally be carried out by a registered healthcare professional and involves an examination of the person’s body and taking a full medical history.
Having carried out an ABCD (E) assessment and decided the person you are with is deteriorating, you will need to report (escalate) your concerns so that rapid and appropriate action can be considered.
It is always best to call for help rather than worry about being wrong; inadequate communication is one of the most common root causes of serious errors. Use the observations you recorded while assessing the person to help pass on accurate information. This will help the next person make an informed decision.
Make sure you have familiarised yourself with the process applying to your work area, that you know who to alert and follow local procedures and processes in place for escalating concerns. If you are lone working with a person who is deteriorating in their own home, call NHS24 or 999 for help and advice. In order to give concise information quickly a tool known as an SBARD is commonly used.
SBARD stands for situation; background; assessment; recommendation; decision. It ensures you mention all the most important pieces of information in the most efficient way possible. Use the notes you have recorded to help with this.
It has five parts.
S – Situation: What is happening at the present time?
B - Background: What are the circumstances leading up to this situation?
A - Assessment: What you think the problem is?
R - Recommendation: What should we do to correct the problem?
D - Decision: What have you agreed?
Your organisation may have a specific SBARD chart for you to fill in.
Your ongoing observation and monitoring of the acutely unwell person will help provide information to show how the person is progressing and demonstrate areas of potential concern as early as possible. You should then report these observations to your supervisor or manager and they will be able to determine the next steps.
You may be involved in carrying out some clinical observations such as:
pulse (heart rate)
breathing (respirations)
blood pressure
oxygen saturation
temperature.
Remember, if you are at any time unsure of what to do when caring for someone who is acutely unwell, you should speak with your supervisor or manager at the earliest opportunity so that there is a clear understanding of what is expected of you and what steps to take.
Always follow your organisation’s policies and procedures on recording and reporting. If you are unsure check with your supervisor or manager.
For more details on the information below have a look at the full clinical skills section of the Royal College of Nursing First Steps document.
When the heart contracts and pumps blood round the body, the vessels the blood runs through (the arteries) expand as the wave of blood passes.
We can feel this pulse where the arteries pass over a solid structure like bone. The wrist is a good example.
The pulse, its rate (the number of times per minute we can feel the pulse), its strength (whether it’s full and bounding or weak and thready) and its rhythm (regular or irregular), can tell us a lot about the person’s state of health.
Changes to the pulse like this may, or may not, be important. What is important, however, is that you detect the changes, and record and report them to your supervisor or manager.
You can learn more about checking the pulse by watching this short video.
Measuring the heart rate
The rate and type of respirations give us important information about people’s general health status.
In addition, breathlessness is a very distressing symptom for many people, and it’s important we are skilled in assessing breathing (respiration) to identify and deal with problems early.
Normal respiratory rate for a man is about 14 to 18 breaths per minute and for a woman 16 to 20 breaths per minute, but it’s more important to know what is normal for the individual, and to assess changes from that level.
More importantly, absence of breathing is often the most obvious sign that a patient has had a collapse and requires immediate basic life support (if appropriate).
You can learn more about checking breathing by watching this short video.
Measuring the respiratory rate
Blood pressure is the force the blood exerts on the walls of the blood vessels as it’s pushed through the body by the heart.
The blood pressure should be checked as part of routine initial checks of temperature, pulse and respirations.
Normal blood pressures vary widely, but generally a blood pressure that is persistently raised above 140/90 is considered high blood pressure. Low blood pressure generally isn’t a problem if it is the person’s natural state, but a sudden and unexplained fall in (or rise) could be very serious and must be reported immediately. A blood pressure monitoring machine may not be available in care homes so you will need to rely on your observations of breathing and circulation.
You can learn more about checking blood pressure by watching this short video.
Measuring blood pressure
We measure a person’s oxygen levels though the process of pulse oximetry. It’s very important, because oxygen is vital to life and reduced levels of oxygen circulating in the bloodstream can lead to very serious, even fatal, complications for the heart, lung, brain and other organs.
People with severe lung or heart disease, who are unconscious or who have difficulty breathing, or who need oxygen treatment for any reason are at risk of reduced oxygen levels, and consequently serious illness.
A pulse oximeter may not be available in care homes so you will need to rely on your observations of breathing and circulation.
Normal levels are between 95% and 100%, although they may vary according to the person’s age and general condition. A level of under 90% is usually cause for alarm and will need prompt attention.
Most people who are having their oxygen levels checked through pulse oximetry will do so on a constant basis and duration will be set out in the person’s care plan.
You can learn more about measuring oxygen saturation by watching this short video.
Measuring oxygen saturation
There’s a very complex set of processes within our bodies that work constantly to keep our body temperature within the normal range (usually considered to be 36.8ºC, although it can vary normally by a degree either side of this).
The body needs to be kept in the normal temperature range so all the other processes it goes through can take place effectively.
A rise in body temperature from the normal range is called pyrexia and might indicate an infection.
You can learn more about measuring temperature by watching this short video.
How to measure temperature
Safe administration of oxygen
Oxygen therapy usually needs to be prescribed for each individual, unless in an emergency situation or under a specific protocol.
This needs to be reviewed as soon as possible by a registered practitioner such as a GP or nurse practitioner.
Remember, if you are at any time unsure of what to do when caring for someone who is acutely unwell, you should speak with your supervisor or manager at the earliest opportunity so that there is a clear understanding of what is expected of you and what steps to take.
You should always follow your organisation’s policy and procedures on the safe administration of oxygen.
Please be aware the resources given here were developed before the COVID-19 pandemic and the use of personal protective equipment (PPE) is not shown. You should use appropriate PPE according to current guidelines. You can keep up to date with current guidelines on the Health Protection Scotland website.
Within most care homes in Scotland, the company Dolby supply oxygen cylinders for use.
These are heavy cylinders which are usually transported from a secured storage facility to a home.
However, if you perhaps have not had oxygen delivered previously then ask for advice regarding suitable storage facilities.
When oxygen is in use it presents specific hazards thus it is important that staff, residents and relatives are aware of this. For more information visit the Dolby Vivisol website.
Where oxygen has been prescribed, it will also specify the type of mask for the person and the oxygen flow rate in litres.
Before setting up oxygen therapy you should explain to the resident what is going to happen as they may be distressed and scared.
The following video describes the key principles behind the choice of mask and how to attach the tubing and mask.
It also describes how to set the flow rate using a portable oxygen cylinder.
Oxygen Therapy and Delivery - How to Prescribe Oxygen
The organisation mentioned at the end of the video is the British Thoracic Society and they have further in-depth information if required.
When individuals receive oxygen, it can cause them to have a dry mouth and or nasal passages.
You should provide regular mouth care and keep the person hydrated to help keep them comfortable. A lip salve or moisturiser may also provide comfort.
Where the mask or nasal prongs irritate the skin (or cause pressure damage) look for ways to ease the pressure by placing swabs between the face and mask or use a barrier cream.
Please note that oil or petroleum jelly-based products are not recommended due to increased fire risk.
When a person is receiving oxygen, you may be asked to record an oxygen saturation rate as this will inform judgements on how effective the oxygen therapy is.
(Guidance about oxygen saturation rate is in the Observations section above).
Where this is palliative (and is to provide comfort only), this may not be deemed necessary. However, you may record their respiratory rate and / or describe their breathing pattern again to show improvement or to provide comfort.
If you are not sure seek advice and support from other team members and your supervisor or manager. Make sure you keep yourself up to date with your organisation's policies and ensure you have undertaken appropriate and relevant training.
The care home or service where you work may have specific charts for you to use for observations. In some instances, all observations will be recorded to identify and escalate care for people who may be deteriorating (revisit the Escalation section above for more information).
