Need help with Vital Signs Scenario ASAP!

S.T.A.C.E.Y, LPN · Jan 15, 2007

Surgery...blood loss....shock....vitals are showing that you should be looking closer into shock.

Might also look into infection, although I'm not sure if it would happen that quickly.

NeosynephRN · Jan 15, 2007

I second shock...with her HR and Respirs going up like that and she has a signifigant drop in her B/P...that makes me think hypovolemia and possible bleeding somewhere!!

S.T.A.C.E.Y, LPN · Jan 15, 2007

What will you do with this information? What will you assess further?

I'd do vitals more frequently to ensure the pt doesn't drop off or something. I'd also reassess the drain in place or the wound dressing, look at urine output, and check the IV fluid hanging. If the pattern continued, you'd want to do something about it, starting with a call to the MD or following orders already in place.

edgwow · Jan 15, 2007

Call the Doctor, intern or resident, first, tell them to come and evaluate this patient

Listen to the patients lungs for breath sounds

look for signs of dehydration skin tenting, color of skin, changes in color of nailbeds, put patient on pulsox machine ( to monitor amount of oxygen in the blood) be prepared to give oxygen and have the MD assess the patient. The patient may need Intravenous fluids,may have had significant blood loss, may be internally bleeding.

nurse4theplanet, RN · Jan 15, 2007

Agree with all the above responses! Pt is definitely in shock (sudden drop in BP, increased HR, increased RR). Too early for an infection, temp may be spiked due to general complications from anesthesia. A call to the MD/Surgeon is your top priority. From there you want to continue monitoring vital signs frequently, assess for signs/symptoms of bleeding, control any loss of fluid/blood that is possible, maybe put the pt in trendelenburg to increase perfusion to the brain until you have orders from the MD for fluids/Blood products, pressors, or a trip back to surgery.

Lammmster · Jan 17, 2007

Agree with everyone else, definitely call the physician and monitor more closely as shock seems evident with the drop in BP, increase HR. I would not call it sepsis just yet, did not spike a fever.

rags · Jan 17, 2007

I agree as well with all the observations & interventions mentioned already. The elevated temp is expected post op and is not considered high enough for concern just yet. Watch it though for continual increase.

I was just wanting to add the rational behind everyone's concern in relation to the HR and B/P for the initial poster to be sure they understand what they are seeing...

With shock (or hypovolemia) the b/p will drop creating a lower cardiac output, this in turn causes the heart to beat faster to compensate and increase profusion (increased hr) if the problem isn't resolved you will see a decrease in the hr as well as a later stage of shock. I would also want to know how strong their pulse is and are they clammy? Urine output is also a vital thing to know, however, depending on the type of surgery they may not have much 2 hours post op anyway, even without shock. The B/P, Pulse rate, and Resp. are what are telling you this pt is in possible shock and needs to be considered for bleeding somewhere. Too bad we weren't given their est. blood loss during surg. I think I would be looking for that information in the chart as well.

Being that this pt is 2 hrs post-op they should still be on continuous pulse ox and vs q 30 minutes IF they had been showing stability after surgery. Do to the lower b/p and increased hr and resp. They should have continued on q 15 min. vitals at minimum. Correct or am I all wet here?

rags

Lammmster · Jan 17, 2007

Could not have said it better myself rag

Pat_Pat RN · Jan 21, 2007

I might be late, but a P.E. could also cause these symptoms, if I'm not mistaken.

But the shock would be my first thought also.

Pat

cardiacRN2006, ADN, RN · Jan 21, 2007

The temp is a red herring. They want to see how many students are going to jump at the infection/surgery thing and miss the other vitals.

Not that a temp isn't possible, but in nursing school speak, they always have questions that are aimed at students jumping at the first bit of info without looking further.

classicaldreams · Jan 21, 2007

I'm in 1st semester of the ADN program, and I have vital signs worksheets to do, but we haven't gone over vital signs in class yet.. so, I'm completely lost. :uhoh21:
Here is the scenario:
A female patient's vital signs prior to surgery are - 98.2, 78, 18, 138/72
Two hours after surgery her vital signs are - 99.1, 102, 26, 92/44
What will you do with this information? What will you assess further?
If anyone could help me with this, I would really appreciate it. I don't know where to start.

I see nursing professors still think these kind of exercises are productive. It was frustrating then to get them, and it was reinforced when I started working in a hospital how little some programs prepare you for the real world. Go back to your professor and tell him or her this isn't nearly enough information to act upon. A full assessment and history is needed. Doesn't matter what your answer is--it will be wrong because the cause and treatment will have many answers. Unless you are triaging a patient after surgery in the desert where there is only you, the patient, and a dinamap, exercises like these are just a waste of time.