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A 75 year old man is admitted to hospital with severe chest pain. The figure shows his observation chart.
Questions
1 What is the first sign on this chart of important clinical deterioration?
2 At what point does the fall in blood pressure concern you?
3 What do you surmise about the reduction in heart rate?
Answers
1 What is the first sign on this chart of important clinical deterioration?
An increasing respiratory rate is the first and most important indicator of severe illness, although anecdotally it is the vital sign least accurately calculated. Extensive research into predictors of mortality based on observation charts has shown that a respiratory rate greater than 27 breaths per minute is an important predictor of cardiopulmonary arrest. 1
Interestingly, at first glance the vital sign that stands out the most on this observation chart is the decrease in blood pressure; a fall in blood pressure is, however, a late sign of deterioration.
Another relevant sign of clinical deterioration is an increasing requirement for oxygen to maintain adequate saturations-in other words, a change from room air to 2 L/min of oxygen by mask to 4 L/min by mask, and so on, to maintain a similar oxygen saturation (commonly known as the "oxygen creep"), which, similar to the increasing respiratory rate, is not obvious unless actively sought out. This is particularly important as increasing oxygen levels may be required to prevent hypoxaemia in a decompensating patient who is deteriorating. This will not be evident from the...