Vital Signs and Trend Recognition

Vital signs are the foundation of patient assessment. While individual values matter, the trend of vital signs over time often provides the most critical clinical information. The Next Generation NCLEX (NGN) emphasizes this pattern recognition skill.

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Normal Adult Vital Sign Ranges

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Trend Recognition: The NGN Approach

The NGN presents data across multiple time points and asks you to recognize patterns. This reflects real clinical practice where deterioration is identified by comparing current values to previous ones.

Key Questions to Ask

1. Is there a pattern? (Progressive increase or decrease)
2. How significant is the change? (Minor fluctuation vs. major shift)
3. Do the trends correlate? (e.g., rising HR + falling BP = shock)
4. What is the underlying cause? (Connect to pathophysiology)

Example Trend Analysis

Pattern Recognition:

• HR: Increasing (compensatory tachycardia)
• BP: Decreasing (decompensation)
• RR: Increasing (respiratory distress)
• SpO2: Decreasing (hypoxia)

Conclusion: This patient is showing signs of hypovolemic shock or sepsis and requires immediate intervention.

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Recognizing Shock

Shock is inadequate tissue perfusion. The body compensates initially, then decompensates.

Early (Compensated) Shock

Key Point: Blood pressure is often NORMAL in early shock. Tachycardia is the earlier and more sensitive indicator.

Late (Decompensated) Shock

Types of Shock

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Increased Intracranial Pressure (ICP)

Cushing's Triad

Cushing's Triad is a late sign of increased ICP indicating brainstem herniation. It consists of:

Critical Point: Cushing's Triad is a late, ominous sign. Earlier signs of increased ICP include:

• Headache
• Vomiting (often without nausea)
• Altered level of consciousness
• Pupil changes (unilateral dilation)

ICP Nursing Interventions

• Elevate head of bed 30 degrees (promotes venous drainage)
• Keep head midline (prevents jugular compression)
• Avoid activities that increase ICP (Valsalva, coughing, straining)
• Maintain quiet environment
• Administer osmotic diuretics (Mannitol) as ordered
• Prepare for possible intubation/hyperventilation

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Orthostatic Hypotension

Definition: A drop of ≥ 20 mmHg systolic or ≥ 10 mmHg diastolic when moving from lying to sitting/standing.

Causes:

• Hypovolemia/dehydration
• Medications (antihypertensives, diuretics)
• Autonomic dysfunction
• Prolonged bed rest

Nursing Assessment:

1. Measure BP lying down (wait 3 minutes)
2. Have patient sit or stand
3. Measure BP after 1 minute and 3 minutes
4. Document position and time with each reading

Interventions:

• Teach patient to rise slowly
• Increase fluid intake (if appropriate)
• Review medications
• Fall precautions

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Temperature Considerations

Fever (Pyrexia)

Nursing Considerations:

• Assess for infection source
• Blood cultures before antibiotics (if ordered)
• Antipyretics as ordered
• Monitor for dehydration

Hypothermia

Nursing Interventions:

• Remove wet clothing
• Warm blankets, warm IV fluids
• Cardiac monitoring (dysrhythmia risk)
• Handle gently (avoid cardiac irritability)

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Respiratory Assessment

Respiratory Patterns

SpO2 Interpretation

Limitations of Pulse Oximetry:

• Inaccurate with poor perfusion
• Inaccurate with nail polish (blue/black)
• Does not detect hypercarbia (high CO2)
• Carbon monoxide gives falsely high readings

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On the Exam

NGN trend items will show vital signs across time and ask you to:

• Identify the most concerning finding
• Recognize the pattern of deterioration
• Prioritize which patient needs assessment first
• Select appropriate interventions

Priority Tip: When presented with trending vital signs, always look for the PATTERN. A patient whose HR has gone from 80→100→120 while BP dropped from 120/80→110/70→95/60 is deteriorating and needs immediate attention, even if individual values might not seem "critical."