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.
Thanks so much
for reading. Is there anything you’d like me to blog about? Just enter into the
comment section. Would love to hear from you!
Take care and
stay connected
Renee
For more great tips, make sure you "like" me on Facebook,"follow" me on Twitter and YouTube and subscribe to my blog. Also, check out my new book on nurse-to-nurse bullying and my new eBook titled, Survive and Thrive: A guide helping new nurses succeed!
No comments:
Post a Comment