Vital Signs

Question 1

What is the normal heart rate?

Answer 1

60 - 100 beats per minute

However, it varies for each patient.

Question 2

What is the normal response of heart rate to treatment?

Answer 2

Slow and gradual increase in heart rate up to 20 beats higher than normal heart rate per minute

Question 3

What is an abnormal response of heart rate to treatment?

Answer 3

• Increase in heart rate greater than 20 beats per minute
• Decrease in heart rate
• Change in rhythm

Question 4

What are exceptions to the rules regarding changing heart rate?

Answer 4

• Some patients cannot tolerate any change in heart rate
• Some patients (who present otherwise medically healthy) can safely go beyond 20 beats per minute.
• Some medications can cause a blunted heart rate response

Question 5

What is the normal blood pressure?

Answer 5

• Systolic less than 120mm Hg

- Diastolic less than 80mm Hg

Question 6

What is the normal response of blood pressure to treatment?

Answer 6

• Slow, gradual, slight increase in systolic blood pressure with activity.
• No change or slight decrease in diastolic pressure

Question 7

What is abnormal response of blood pressure to treatment?

Answer 7

• Increase or decrease I systolic blood pressure greater than 20 points
• Decrease of diastolic blood pressure greater than 10 points

Question 8

What are the exceptions to the rules regarding blood pressure?

Answer 8

• Sometimes in ICU a patient’s blood pressure is maintained high to profuse the brain (200/100)
• Always check with the team if therapy is appropriate when this is the case.

Question 9

What is the normal oxygen saturation? (02)

Answer 9

92-100 percent

Question 10

What is the normal response of 02 to treatment?

Answer 10

A slight drop or increase in 02 saturation

Question 11

What is the abnormal response of 02 to treatment?

Answer 11

Drop in 02 saturation below 92% (unless that is baseline)

Question 12

What are some exceptions to the rules regarding 02 treatment?

Answer 12

In some instances, the team deems it safe to titrate the patient’s 02 by increasing it via nasal cannula. However, a written order to do this is required from the MD as 02 is considered a form of medication.

Question 13

What are the four steps of initiating treatment?

Answer 13

1. Check to make sure OT orders are active.
2. Review the patient’s medical record
3. Review the patient’s current status with the medical team
4. Begin evaluation and treatment with a gross assessment of mental status, strength and vital signs

Question 14

What is telemetry?

Answer 14

It detects heart rate and rhythm. It is similar to an electrocardiogram (ECG).

Question 15

How is an ECG different to bedside telemetry?

Answer 15

An ECG is read by placing 12 electrical leads to read heart rate and rhythm while telemetry uses either 3-5 leads.

Question 16

What is a Foley catheter?

Answer 16

It is used to drain urine from the bladder.

Question 17

What is an external ventricular drain (EVD)?

Answer 17

A small tube inserted into the ventricles of the brain that drains cerebral spinal fluid.
It is used when the intracranial pressure is elevated. The tube is connected to a device that measures the amount of fluid being collected.

Question 18

What are some things to be aware of if a patient has an EVD?

Answer 18

• The head of the bed must be elevated at a specific level
• Only nurses can clamp an EVD
• If an EVD is not clamped, a patient’s bed should not be moved nor should the patient be mobilised

Question 19

What is an intracranial pressure monitoring catheter (ICP)?

Answer 19

A catheter inserted into the ventricles of the brain via a burr hole. It measures any changes to intracranial pressure.

Question 20

What are some things to be aware of if a patient has an ICP?

Answer 20

• It is used in injuries such as haemorrhages, aneurysms, head trauma that may lead to swelling or an elevation in intracranial pressure.
• The head of the bed is usually elevated a certain amount as the intracranial pressure will increase when the head of the bed is lowered
• Generally, ADL treatment and mobilisation is held during this time, however splinting or positioning may be implemented with physician approval.

Question 21

What is a spinal drain?

Answer 21

A spinal drain is a catheter placed in the lumbar spine to drain CSF. It is used to treat any leakages of CSF and drain excess fluid.

Question 22

What are some things to be aware of if a patient has a spinal drain?

Answer 22

• The lumbar drain should be set to drain bellow the level of leak
• When the drain is opened, patients are placed flat on their back to allow for drainage.
• Patients with this drain may get up and out of bed and may engage in ADLs.