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Pearls and pitfalls in vital signs
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Pearls and pitfalls in vital signs

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  • 1. The Critically Ill PatientPearls and Pitfalls inVital Signs
  • 2. 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).
  • 3. 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)
  • 4. 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?
  • 5. 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
  • 6. PMHx + Medications
    Metformin 500mg BD
    Metoprolol 100mg BD
    Citalopram 20mg
    Seritide BD
    Verampril 120mg
    Type 2 DM
    IHD
    Asthma
    ED
    Obesity
    Depression
    HT
  • 7. The Assessment
    Airway
    Breathing
    Circulation
    Disability
    Exposure
  • 8. When to take Vital Signs
    Pt vital sign frequency and duration should be taken based on clinical assessment, not protocols or ward culture.
  • 9. Documentation
    Patients are either compensating or de-compensating.
    Stable is where horses live!!!
  • 10. Clinical signs of critical illness
    Tachypnoea
    Tachycardia > Bradycardia
    Hypotension
    Altered conscious state (lethargy, confusion, restlessness or falling GCS)
    Poor Urine Output
    Looks like SHIT!!!!
  • 11. 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.
  • 12. 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.
  • 13. 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)
  • 14. 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
  • 15. 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.
  • 16. 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??
  • 17. 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
  • 18. 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.
  • 19. Conscious State
    A.B.C.Dont Forget The Glucose!!!!
    Look at:
    Hypoxia
    Hypoglycaemia
    Infection (sepsis)
    Delirium
    Electrolytes
    Cerebral vascular events
    Toxicology
  • 20. 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).
  • 21. 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
  • 22. The End!!!