When is high too high?

[Maddy_Rose]

I had a trauma/head injury patient these last 2 shifts with a spike in their vitals signs and wanted to get another opinion -

This patient's baslines usually ran between 120-130 for heart rate, I can't remember what it was in the morning but normal or I would have made note. I checked it again in the afternoon (just scheduled neurovitals, nothing had happened) and the heart rate was going 143-145, all other vitals normal, BP was fine. What do you guys consider a significant change from normal when talking about heart rate? Would you have informed the Doc even though other vitals were normal, or monitor? This patient could only make incomprehensible sounds so I was unable to ask if they felt symptomatic of it.

[TawniAline]

don't have call orders listed? we have standard call orders if hr>115 and docs change it accordingly if there is a known stable tacchycardia- but even then gen. the pt is kept on tele...

[AJJKRN]

With a TBI, I would also want to try and figure out if the increased HR is from the head injury or not. Usually I see a Pt having a hard time regulating thier body temp but breathing and heart rate regulation are in the same area...medulla oblongota baby!

I'd a called the MD, they need to give parameters...

I was once given advice by a seasoned nurse that is outstanding in their job which was, If a thought crosses your mind to call then you should probably call, nursing is an instinct just like being a parent watching over and protecting thier young.