What do you do - Vital Signs...

[LTC LPN 2006]

This may be a dumb question, but being a new nurse I don't have the experience to immediately know what to think or concider. So here is my question: What do you do when vital signs are high or low?

Ex.
High Temp
Low Temp
High Pulse
Low Pulse
High Resp
Low Resp
High B/P
Low B/P

I can handle a high temp by giving tylenol but the other day I had someone w/ temp 93.6 - what would be your next step? It ended up her B/P was also elevated and blood sugar was around 43. Not really sure why.

Since I'm new I always check with the other nurse when something is off to get another opinion on what to do, but any advise would be greatly appreciated!!!

[cassioo]

you have to assess your pt and find out the reason for the v/s. Is it different then it has been or is it norm for that pt. If temp is low have they been eating ice? do they feel cold, is the equipment working right and being used right? For change in pulse, b/p are they in pain or bleeding or have they taken some medication? Treat the patient not the numbers.

[SoldierNurse]

This may be a dumb question, but being a new nurse I don't have the experience to immediately know what to think or concider. So here is my question: What do you do when vital signs are high or low?

Ex.
High Temp
Low Temp
High Pulse
Low Pulse
High Resp
Low Resp
High B/P
Low B/P

I can handle a high temp by giving tylenol but the other day I had someone w/ temp 93.6 - what would be your next step? It ended up her B/P was also elevated and blood sugar was around 43. Not really sure why.

Since I'm new I always check with the other nurse when something is off to get another opinion on what to do, but any advise would be greatly appreciated!!!

Tylenol is not the only action to be taken for a high temp. I'd get blood cultures, Chem10, UA/UA CX, and assess the patient for any other objective/subjective symptoms. Plus, besides tylenol I'd place ice packs under bilateral armpits.

Regards to your list of other high/low; treat the specific patient & situation. In otherwords, what system failures are going on with the patient? Infection [WBC count?]? Pain? Internal bleeding?

Sounds like your patient was in a hypoglycemic crisis I needed an amp of D50.

[cougarnurse]

What is the running diagnosis?

If my rezzie is a diabetic with a low BGM, I'd usually have them eat Graham Crackers and OJ; one diabetic is a confirmed Glucagon. Of course, I would recheck the BGM, just because..... Then there are the non-diabetics who dip a bit.

Also, not everyone has the 'standard' 98.6 temp. I know of people who are lower, and some who run higher. The same goes for BP's, etc.

'Cat'

[LTC LPN 2006]

I work in a nursing home and 3rd shift, my options for what I can actually do are pretty limited. I don't have the ability to get labs done and hate to wake a doctor up in the middle of the night without being completely sure it is urgent and I have fully assessed all that I could and have all the information available. I can take vitals, use my stethoscope, check blood sugar, and make observations so what things along those lines should I be focusing on?

[LTC LPN 2006]

I always first look at their vitals sheets for the last few weeks/months and compare to see if the vitals are normal for that resident. Its when they are not normal for the resident that I am unsure of the best plan of action. I always double check to be sure the value was correct and that it wasn't an equipment problem or the CNA didn't write the numbers incorrectly.

Just out of curriousity when a person has an increased temp, what value do you start to take action for (such as giving tylenol). For example if it is 98.6 Axillary, would you just monitor the low grade temp or would you medicate? And what value on the high side do you concider to be too critical and call the MD imediately instead of waiting to see if the temp can be reduced by other means (tylenol, ice packs, etc)??

[cougarnurse]

I let low grad temps go for a while. 101 ax is a bit high, and if there is confusion and other sx....ok, time to call the doctor after the Tylenol/trying other measures.

[cassioo]

never hesitate to call the doctor if you think there is a need. If you don't and something happens it's you on the line. When you have your full assessment done call. If the doctor doesn't want called for a temp he should have standing orders that you follow then call if you don't get results. If you don't have that maybe you could bring that to someone in charge who could take it to the doctor(s).

For that high temp besides tylenol do the remove excess blankets and clothing. I prefer just cool wash clothes to ice packs unless you have an unresponsive temp that's over 103 for an adult...(I had 102 with my recent hospitalization and was shivering and they got out the ice packs. Normally at home for myself I take a warm shower to get the shivering to stop..also temp goes up which isn't good but I hate the shivereing then work on getting it down) That ice was awful but did it with the pain medication.

[SoldierNurse]

...Just out of curriousity when a person has an increased temp, what value do you start to take action for (such as giving tylenol). For example if it is 98.6 Axillary, would you just monitor the low grade temp or would you medicate? And what value on the high side do you concider to be too critical and call the MD imediately instead of waiting to see if the temp can be reduced by other means (tylenol, ice packs, etc)??

If the patient is asymptomatic w/< 99.5 F [oral] I'd continue to monitor, rather than medicate. However, geriatric patients usually have a cooler core temp than the so called 98.6F norm. So, keep in mind it is beneficial to know each individual's baseline, if such data is available. Anyway, I'd admin tylenol 650mg PO, or rectal for HA w/low grade temp. BTW, the rectal route will usually bring about quicker results.

An oral temp of 101F warrants MD notice... I don't care if it is in the middle of the night. I've seen temps continue to climb above 101F, if no immediate action is taken.

[LTC LPN 2006]

This may be a dumb question but...

If a resident has a PRN order for Tylenol 650 mg PO for pain/fever are you allowed to give liquid tylenol instead of tablets? Can you give a suppository? Or do you technically need an order to be given as a suppository?