Recognition of a failing patient

Question 1

Mean arterial pressure

Answer 1

less than 70 or more than 130 mm Hg

Question 2

Heart rate

Answer 2

less than 45 or more than 125

Question 3

Respiratory rate

Answer 3

less than 10 or more than 30 (accessory muscle use, adventitious breath sounds, weak cough, threatened airway)

Question 4

hypertension

Answer 4

uncontrolled hypertension

Question 5

Pain

Answer 5

complaints of chest pain not controlled by nitroglycerine/ cardiac arrythmias

Question 6

Mental status

Answer 6

change in mental status (confusion, drowsiness, prolonged unexplained agitation)

Question 7

More red flags

Answer 7

hemmorhage
new, frequent intractable seizures
sudden loss of movement or weakness of face, arm or leg
diaphoresis
dyspnea
change in color of central or peripheral skin (pale, dusky, gray or blue)
acute onset of pain or sudden increase in quality of pain
oliguria

Question 8

nurse’s responsibilities while waiting for code teams

Answer 8

stay with the patient
assess vital signs/blood glucose
insure reliable IV access
enlist the aid of a colleague
get the crash cart to the bed side
set up oxygen and suction
position the patient on the back board in case cardiopulmonary resuscitation is needed