What critical vital signs would institute a rapid response

  1. 0
    I'm still a little foggy as to what would be a signal to cal a RR obviously if pt looks in distress but what critical sbp? Pulse, o2, rr.. Thanks!
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  3. 27 Comments so far...

  4. 6
    You can't always go by "just" numbers. You have to use your critical thinking too and oh yeah, the patients presentation. The most important thing.
    herring_RN, cardiacfreak, KelRN215, and 3 others like this.
  5. 2
    There should be orders ie call physician if sbp>____ or HR>____ etc so you call before it gets critical
    cardiacfreak and Altra like this.
  6. 8
    You also have to take into account each patient's "normal" vitals. A SBP of 88 might be okay for a healthy, thin 22 year old. But for an obese 50 something year old who smokes, a systolic blood pressure of 88 would be "abnormal" If his normal was 140 to 150.

    We also call a rapid response for new onset of seizures or altered LOC.

    Staff members are also strongly encouraged to activate the rapid response if they have any concerns regarding a change in a patient's condition or that gut feeling that something just isn't right.

    And I'm a firm believer that calling a rapid response and having it end up nothing is way better then ignoring symptoms and the situation turning into a code.
    tcvnurse, herring_RN, redmielita, and 5 others like this.
  7. 1
    each facility has their own protocol for activation of the RRT.....these are some standards.

    heart rate: 40< or >130 beats/min
    systolic blood pressure: <90 mm Hg

    respiratory rate: 8< or >28 per min

    pulse oximetry reading: <90% despite oxygen administration

    urine output: <50 ml over the last 4 hours

    conscious state.


    This is a nice resource from the ICSIInstitute for Clinical Systems Improvement

    ......https://www.icsi.org/_asset/8snj28/R...active0711.pdf

    THe AHRQ......Agency for Healthcare Research and Quality( we have a AHRQ forum....http://allnurses.com/ahrq-effective-health/) also has some great resources.National Guideline Clearinghouse |
    elprup likes this.
  8. 1
    It is not as easy as just a number as mentioned previously. Is this new, what is the pts norm, did you just give BP meds, came back from surgery and still waking up. Many times it is facility based as when to call..What is your facilities policy re this.. Look it up, or ask.

    I am one of the RR nurses at my facility and we have a policy with numbers to call for, new onset CP etc or simply because a pt has you concerned.. You may be able to call the RR nurse and talk to them; education is part of what we do. I can say, we are always willing to help. I have had several shifts the charge nurse or the floor nurse would call just to ask a question..Many times we would come over and take a look but we are free meaning we don't take pts when we are RR. It may be different in your facility.
    Susie2310 likes this.
  9. 0
    Assess the patient first before anything else...
  10. 0
    As others have said each facility has their own guidelines, and sometimes even when we have followed the guidelines I have had to defend why we called one.
  11. 0
    We call it MET (Medical Emergency Team) at my facility...but the criteria are similar to what others have mentioned. However, I wouldn't arbitrarily call rapid based on a vital sign number. You need to assess the patient. I work on a hepatobiliary/GI medsurg/transplant floor...many of my liver patients walk around with SBPs in the low to middle 80s and are totally fine. We also can call if we just feel something isn't right...family members/visitors can also call MET at my facility.
  12. 8
    It's not just having a checklist of numbers, because if that's all you go on, when somebody asks you, "Didn't you think that when the BP dropped over six hours from 180 systolic to 104 systolic with no changes in medication that something had to be going on?" you won't have a better answer than, "Well, our BP for calling RRT is <100." Trends are more important than individual data points.

    I know that new grads in particular don't want to rock the boat, don't want to look dumb, and don't want to call RRT and get embarrassed. They are too close to the student clinical checklist mentality and not experienced enough to have good enough assessment skills to have good judgment yet. Always ask for a second opinion from a more experienced nurse if you see trends developing.
    cardiacfreak, psu_213, KelRN215, and 5 others like this.


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