Order of warning signs in shock
Heart Rate Rises First
- 1Heart rate rises
- 2Respiratory rate rises; restlessness or anxiety
- 3Urine output drops
- 4Confusion, decreased LOC
- 5Blood pressure drops (late)
Pearl: Compare to the client's own baseline. RR change is the best predictor of decline.
When you need it: A post-op client's HR went from 72 to 104 over 4 hours. BP is normal.
Rising intracranial pressure
Cushing's Triad: Wide, Slow, Odd
- WideWidening pulse pressure (high systolic)
- SlowBradycardia
- OddIrregular respirations
Pearl: A late sign of herniation: emergency.
When you need it: A head injury client: BP 184/62, HR 48, irregular breathing.
Getting an accurate vital sign
Count Without Telling
- CuffRight cuff size
- ApicalApical pulse before digoxin
- SecretCount respirations without the client noticing
- MinuteIrregular rhythm: count a full minute
When you need it: Why keep your fingers on the wrist while counting respirations?