Editing Reduction of Risk Potential – RN Flashcards (section)

== Vital Signs and Hemodynamics ==

;Earliest reliable signs of hemorrhage and shock, before hypotension appears
:Tachycardia, tachypnea, restlessness and anxiety from cerebral hypoperfusion, cool clammy skin, and a narrowing pulse pressure.

;Cushing triad and what it indicates
:Widening pulse pressure with rising systolic pressure, bradycardia, and irregular respirations. It is a late and ominous sign of markedly increased intracranial pressure and impending herniation.

;Definition of orthostatic hypotension
:A fall of at least 20 mm Hg systolic or 10 mm Hg diastolic within three minutes of moving to standing, usually with a compensatory rise in heart rate. It is a major fall risk.

;Situations in which pulse oximetry is unreliable
:Poor perfusion, hypothermia and vasoconstriction, motion, severe anemia, certain nail polish and artificial nails, and carbon monoxide poisoning. It also does not reflect ventilation, so it can be normal in significant hypercapnia.

;Most likely cause of fever in the first 24 to 48 hours after surgery, versus later
:Atelectasis early. Later fever suggests urinary tract infection, wound infection, pneumonia, or venous thromboembolism.