Deterioration Flashcards
1
Q
What happens to BP during deterioration?
A
-Decreases (usually a late sign)
2
Q
What happens to HR during deterioration?
A
-Tachy (Usually a late sign)
3
Q
What is normal respiratory rate?
A
11-17
4
Q
What happens to RR during deterioration? What should the nurse look out for?
A
RR change Note: (first signs, observe) -WOB -Use of accessory muscles -Lung expansion -Colour of pt
5
Q
What are other things to notice?
A
Change in:
- Temp
- Pain
- Fluid balance
- Blood analysis
- Family concerns
6
Q
What are the nursing interventions?
A
- Airway
- Breathing
- circulation
- Disability
- Exposure (escalation)
- Document
- Review notes and trends
- ECG
- Meds where appropriate.
