Pearls and pitfalls in vital signs
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Transcript of Pearls and pitfalls in vital signs
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The Critically Ill PatientPearls and Pitfalls inVital Signs
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IntroductionDue to the higher acuity of
patients in hospitals, and rapid turnover of patients, more expectation is placed on nurse’s ability to rapidly assess, intervene, and monitor the health status of patients in their care. (Jevron, 2007).
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Vital SignsAbnormalities in vital signs are
important predictors that determine if patients go to wards, HDU, ICU or the morgue.
Cardiac arrest in hospital generally results from the final step in a progressive deterioration.
Survival to d/c from cardiac arrest in SCGH is 19-22% (Met report 2007)
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Case StudyMr Rectal Prolaspe (62yo) is day
3 post laparotomy for BO, you go into his room and notice he’s diaphoretic, pale, cool to touch, sitting on the edge of the bed, and only speaking in words to you.
What do you do?
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Vital SignsPulse 95 regRR 28BPMBP 118/75Temp 35.6Sao2 95% on 3lNPU/O 105mls past 3/24BSL 4.6mmol
Dose this PT meet met criteria
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PMHx + Medications
Metformin 500mg BD
Metoprolol 100mg BD
Citalopram 20mg
Seritide BDVerampril
120mg
Type 2 DMIHDAsthmaEDObesityDepressio
nHT
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The AssessmentAirwayBreathingCirculationDisabilityExposure
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When to take Vital SignsPt vital sign frequency and
duration should be taken based on clinical assessment, not protocols or ward culture.
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DocumentationPatients are either compensating
or de-compensating.Stable is where horses live!!!
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Clinical signs of critical illnessTachypnoeaTachycardia > BradycardiaHypotensionAltered conscious state (lethargy,
confusion, restlessness or falling GCS)
Poor Urine OutputLooks like SHIT!!!!
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Met CriteriaA: ThreatenedB: All respiratory arrest Respiratory Rate <5 or > 36C: All cardiac arrest Pulse rate <40 or >140 Systolic BP <90D: Fall in GCS of <2 points (sudden) Repeated or prolonged seizureUrine output : unexplained fall <100ml over
3/24Any pt that your seriously concerned about
that dose not meet above criteria.
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PulseIs the Pt on BB,CCB or Pacemaker
these will blunt the physiological stress placed on the heart.
A pulse of >90 may be tachycardia for these patients.
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Respiratory RateThe Neglected Vital Sign!!RR >27 is the most important
predictor of cardiac arrest in hospital wards.
RR > 24 require prompt assessment by Dr, to determine underlying cause
(Cretikos, A. Et al. (2008) Medical Journal Australia)
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Respiratory SystemAsk how long can this patient can
compensate for (age, co-morbidities).
Look for accessory muscle useAre they talking in words,
sentences or phrases?Conscious stateCentral/Peripheral Perfusion
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Pulse OximetryRelied on way to much!!!Doesn't measure ventilation only
oxygenationNeed to do ABGs to detect
hypercarbia.Should not replace RR or
respiratory system assessment.
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Blood PressureCheck preop Blood pressureA BP of 120 could be hypotension
in an normally hypertensive person.
Look what is normal for this patient!
Chest pain BP both arms! Why??
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Orthostatic Blood PressuresNot waiting 3 mins in between
doing lying to standing BPsPulse rise more informing than BP
droppingPhysiological response from
baroreceptors
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TemperatureSigns of sepsis (SIRS) <36 or
38>Elderly more prone to
hypothermia (lack of reserves to compensate)
Thermometer probe need to be placed in back sublingual pouch for most effective reading
Keep patients warm, we tend to induce hypothermia.
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Conscious StateA.B.C.Dont Forget The Glucose!!!!Look at:HypoxiaHypoglycaemiaInfection (sepsis)DeliriumElectrolytesCerebral vascular eventsToxicology
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Urine OutputAdult
0.5mls/Kg/Hr Pitfall: 30mls is
often reported by Drs and nurses as adequate
Indicator of cardiac output
Hospital has a policy for Mx: of Oliguria (Medical Services Policy No. 050).
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Fluid BalanceHypovolaemia is a major cause of
cardiac arrest mortality in hospital, result’s in PEA or asystole arrest.
Its much easier to get a patient out of APO, than acute/chronic renal failure
Monitor FBC
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The End!!!