If you were to review the vital signs from patients three days before they coded, which vital sign do you think would change more than the others?
I’ve asked that question to hundreds of nurses over the last few years. Most say heart rate or blood pressure. But they are wrong.
The answer is…..RESPIRATIONS.
Yep. When reviewing vital signs from patients who coded, it was their respiratory rate that changed. Rates went from 18 to 24; or 20 to 28; or even 16 to 20! An increase in respiratory rate can be the first indication that your patient is starting to deteriorate. If you notice, the rates don’t have to increase that much to indicate a big problem. That’s one of the reasons why we often miss this - it's because a change in respiratory rate can be subtle. The other reason is that we typically rely on nursing assistants to check vital signs. If I checked the respiratory rates of every patient on your unit right now, this is what I’d see: 18, 18, 18, 18….or 20, 20, 20, 20…right? We (nurses) and they (nursing assistants) don’t always actually count.
Saved a patient
I recently took care of a post-op lami patient. He was in a lot of pain and although I gave him a several doses of opioids and muscle relaxers, he was still very uncomfortable. I then noticed that his respiratory rate was up and his pulse ox was down. He went from 16 to 24 respirations/min; PO of 96% down to 88%. At first I thought it was because he was breathing shallow due to the pain. So I encouraged deep breathing using the incentive spirometer.
For a short period of time, his respiratory rate and pulse ox would come back to normal but then would become abnormal again. I communicated with his surgeon and initially we both thought that it was from the pain. However, I knew something wasn’t right. I couldn’t stop thinking about his respiratory rate (remembering the studies about respiratory rate increases prior to codes!!!), so I asked the physician if we could just check a CXR. At first he said no that the patient didn’t have any history of heart failure or respiratory disease but I persisted until he caved! Sure enough, the CXR showed acute pulmonary edema!!! No wonder why his respiratory rate was up!! His lungs were filled with fluid. We quickly diuresed him and like textbook, his respiratory rate came back down to normal. I’m convinced we prevented him from coding!
You see, it was the fact that his respiratory rate was elevated that kept nagging me, telling me that something else was wrong…and I was right and I want YOU to be right too.
Although it’s necessary to have nursing assistants check vital signs, there are times when WE need to take a more active role in monitoring – especially respirations. Knowing which patients are at risk can help you to prioritize and delegate appropriately. Be vigilant monitoring patient’s respiratory rates who are post-op, receiving opiods or in the beginning stages of sepsis.
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