The Critically Ill PatientPearls and Pitfalls inVital Signs

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).

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)

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?

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

PMHx + Medications

Metformin 500mg BD

Metoprolol 100mg BD

Citalopram 20mg

Seritide BDVerampril

120mg

Type 2 DMIHDAsthmaEDObesityDepressio

nHT

The AssessmentAirwayBreathingCirculationDisabilityExposure

When to take Vital SignsPt vital sign frequency and

duration should be taken based on clinical assessment, not protocols or ward culture.

DocumentationPatients are either compensating

or de-compensating.Stable is where horses live!!!

Clinical signs of critical illnessTachypnoeaTachycardia > BradycardiaHypotensionAltered conscious state (lethargy,

confusion, restlessness or falling GCS)

Poor Urine OutputLooks like SHIT!!!!

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.

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.

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)

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

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.

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??

Orthostatic Blood PressuresNot waiting 3 mins in between

doing lying to standing BPsPulse rise more informing than BP

droppingPhysiological response from

baroreceptors

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.

Conscious StateA.B.C.Dont Forget The Glucose!!!!Look at:HypoxiaHypoglycaemiaInfection (sepsis)DeliriumElectrolytesCerebral vascular eventsToxicology

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).

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

The End!!!