The Critically Ill PatientPearls and Pitfalls inVital Signs
Introduction Due 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).
Vital Signs Abnormalities 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)
Case Study Mr 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?
Vital Signs Pulse 95 reg RR 28BPM BP 118/75 Temp 35.6 Sao2 95% on 3lNP U/O 105mls past 3/24 BSL 4.6mmol Dose this PT meet met criteria
The Assessment Airway Breathing Circulation Disability Exposure
When to take Vital Signs Pt vital sign frequency and duration should be taken based on clinical assessment, not protocols or ward culture.
Documentation Patients are either compensating or de-compensating. Stable is where horses live!!!
Clinical signs of critical illness Tachypnoea Tachycardia > Bradycardia Hypotension Altered conscious state (lethargy, confusion, restlessness or falling GCS) Poor Urine Output Looks like SHIT!!!!
Met Criteria A: Threatened B: All respiratory arrest Respiratory Rate <5 or > 36 C: All cardiac arrest Pulse rate <40 or >140 Systolic BP <90 D: Fall in GCS of <2 points (sudden) Repeated or prolonged seizure Urine output : unexplained fall <100ml over 3/24 Any pt that your seriously concerned about that dose not meet above criteria.
Pulse Is 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.
Respiratory Rate The 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)
Respiratory System Ask how long can this patient can compensate for (age, co-morbidities). Look for accessory muscle use Are they talking in words, sentences or phrases? Conscious state Central/Peripheral Perfusion
Pulse Oximetry Relied on way to much!!! Doesn't measure ventilation only oxygenation Need to do ABGs to detect hypercarbia. Should not replace RR or respiratory system assessment.
Blood Pressure Check preop Blood pressure A BP of 120 could be hypotension in an normally hypertensive person. Look what is normal for this patient! Chest pain BP both arms! Why??
Orthostatic Blood Pressures Not waiting 3 mins in between doing lying to standing BPs Pulse rise more informing than BP dropping Physiological response from baroreceptors
Temperature Signs 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.
Conscious State A.B.C.Dont Forget The Glucose!!!! Look at: Hypoxia Hypoglycaemia Infection (sepsis) Delirium Electrolytes Cerebral vascular events Toxicology
Urine Output Adult 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).
Fluid Balance Hypovolaemia 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