Vital Signs Flashcards
What is the normal heart rate?
60 - 100 beats per minute
However, it varies for each patient.
What is the normal response of heart rate to treatment?
Slow and gradual increase in heart rate up to 20 beats higher than normal heart rate per minute
What is an abnormal response of heart rate to treatment?
- Increase in heart rate greater than 20 beats per minute
- Decrease in heart rate
- Change in rhythm
What are exceptions to the rules regarding changing heart rate?
- 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
What is the normal blood pressure?
- Systolic less than 120mm Hg
- Diastolic less than 80mm Hg
What is the normal response of blood pressure to treatment?
- Slow, gradual, slight increase in systolic blood pressure with activity.
- No change or slight decrease in diastolic pressure
What is abnormal response of blood pressure to treatment?
- Increase or decrease I systolic blood pressure greater than 20 points
- Decrease of diastolic blood pressure greater than 10 points
What are the exceptions to the rules regarding blood pressure?
- 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.
What is the normal oxygen saturation? (02)
92-100 percent
What is the normal response of 02 to treatment?
A slight drop or increase in 02 saturation
What is the abnormal response of 02 to treatment?
Drop in 02 saturation below 92% (unless that is baseline)
What are some exceptions to the rules regarding 02 treatment?
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.
What are the four steps of initiating treatment?
- Check to make sure OT orders are active.
- Review the patient’s medical record
- Review the patient’s current status with the medical team
- Begin evaluation and treatment with a gross assessment of mental status, strength and vital signs
What is telemetry?
It detects heart rate and rhythm. It is similar to an electrocardiogram (ECG).
How is an ECG different to bedside telemetry?
An ECG is read by placing 12 electrical leads to read heart rate and rhythm while telemetry uses either 3-5 leads.
What is a Foley catheter?
It is used to drain urine from the bladder.
What is an external ventricular drain (EVD)?
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.
What are some things to be aware of if a patient has an EVD?
- 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
What is an intracranial pressure monitoring catheter (ICP)?
A catheter inserted into the ventricles of the brain via a burr hole. It measures any changes to intracranial pressure.
What are some things to be aware of if a patient has an ICP?
- 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.
What is a spinal drain?
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.
What are some things to be aware of if a patient has a spinal drain?
- 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.