Need help, Vital signs

[pjsleew]

Hi All,

I'm in the first semester and cannot find an appropriate answer anywhere. Seriously I have checked all my textbooks and online for an answer.

Any comment would be appreciated.

Interpret the meaning of the following vital signs and dedcide on an action to take. A client is admitted to the unit. The nurse reports that the vital signs are stable and the findings just before transfer were T:97F, P:80, R:20, BP:115/62. You assess vital signs every 15mins and record the following:

T:97, P:80, R:20, BP:115/62

T:97, P:100, R:24, BP:98/82

T:97, P:106, R:24, BP:98/60

What actions would you take?

Thank you in advance.

[vashtee, RN]

I'm a student.... I'm gonna guess that you need to give O2 because the heart rate and respirations are increasing. I don't know about the blood pressure... I would probably check for S/S of dehydration or bleeding.

[UM Review RN, ASN, RN]

Wow, I sure do feel sorry for you students.

Not enough info here, so taking into consideration that you're in the first semester, I'd probably take a manual BP and see what I get. If the next set of vitals continues the trend of HR up, BP down, I'd probably get an O2 sat, apply O2 @ 2L if it was >92%, and call the doc.

(Now don't forget to come back and tell us the answer, ok? Because I won't be able to sleep till I know! )

[APBT mom, LPN, RN]

Recheck bp with a manual. Force fluids IV to bring the pressure up. Give 02. Put the foot of the bed higher than the head of the bed (I know it's trendlenberg but I can't remeber which one oops)to increase the blood going to the heart. Put pt on an EKG machine/tele for continuous monitoring. Call the MD.

I saw this a couple of weeks ago at clinicals. Pt was transfered to the floor and not even 5 mins after pt bp was dropping while pulse and resps were increasing. Hooked the patient up to the defibrilator on the crash cart (the called a rapid reponse) and the patient was in A-fib, pulse 125 resp 30 bp 90's/50's with two lines placed and 2L of fluid fully open running in the patient. Patient ended up going to the ICU so we never found out what happened or what caused it.