Mr. Coburn, the 56-year-old school teacher who was seen earlier in the week for hyperthermia, arrives at the walk-in health center complaining of feeling dizzy and nauseated. You immediately note that he appears to be having some difficulty catching his breath during coughing spells. A new graduate nurse takes Mr. Coburn's admitting vital signs as: pulse 122 and regular, RR 22 and easy, BP 88/50 RA, tympanic temperature 38° C (100.4° F), SpO2 92%. As you enter Mr. Coburn's room, the electronic blood pressure (BP) machine alarm is sounding with cuff on right arm. You note that it is flashing "72 systolic" with no diastolic reading. Mr. Coburn is turned on his right side, and his eyes are closed. His respirations appear labored.

 

1. List in order of priority your first five interventions.

2. Which vital signs should you reassess and which methods should you use?

3. Which hourly vital signs should you delegate to a nursing assistive personnel (NAP)?

Answer:

1. List in order of priority your first five interventions.

(A) Check Mr. Coburn's response by calling out his name or by touching him gently in order to assess the patient's level of consciousness.

(B) Obtain a respiratory rate before repositioning

(C) Reposition the patient with the head of bed elevated, off his right arm where the BP cuff has been placed.

(D) Recheck the BP since this vital sign is critically low. Check if the cuff is properly placed.

(E) Obtain an apical pulse to reassess rate and check for dysrhythmias

2. Which vital signs should you reassess and which methods should you use?

All of the vital signs should be rechecked or reassessed except for the temperature. Assess the pulse for rate and regularity. An irregular heart rate may be causing dizziness. The respiratory rate almost normal and unexpected in a patient who has difficulty catching his breath. The new graduate nurse may have assessed respiratory rate during a coughing spell. The BP should be repeated using a Manual stethoscope and a sphygmomanometer since electronic BP devices are not accurate at high heart rates or during hypotension. SpO2 should be repeated and continuously monitored while the patient has labored breathing, tachycardia, and hypotension.

3. Which hourly vital signs should you delegate to a nursing assistive personnel (NAP)?

Hourly vital signs should not be delegated until Mr. Coburn is stable. Once he is stable, all vital signs can be delegated to the NAP.

Prioritization is ABC (Airway,Breathing, Circulation)