Vital Signs Vigilance
What is the normal range for adult respiratory rate?
What is 12–20 breaths per minute
Name two signs of hypoxia.
What is restlessness, confusion, anxious, agitated, combative, lethargic, tachypnea, unresponsive
What does A stand for in ABCDE?
What is A=Airway
Who should you notify if a patient's condition worsens?
What is rapid response team, Chain of command-Charge nurse, House Supervisor, Manager/Director (Team Lead), physician
What is your first action when you find a patient unresponsive?
What is check responsiveness and call for help (start CPR if no pulse or breathing)
Which is the earliest vital sign to change in a deteriorating patient?
What is Respiratory rate (it's often the earliest indicator of deterioration)
What does a sudden change in LOC (level of consciousness) suggest?
What is a Neurological impairment or possible stroke, hypoxia, or sepsis
How do you assess “C” in ABCDE?
What is Circulation
What is the purpose of a rapid response team?
What is to provide immediate intervention to prevent cardiac or respiratory arrest
What intervention is appropriate for a patient with low O2 sats?
What is apply oxygen via nasal cannula or mask; reposition the patient; call for help if needed
What oxygen saturation percentage typically requires supplemental oxygen?
What is below 94% on room air (generally prompts oxygen therapy, depending on protocols)
Why is chest pain with shortness of breath a red flag?
What is it may indicate pulmonary embolism, myocardial infarction, or pneumothorax
What is the purpose of a rapid ABCDE assessment?
What is to identify and manage life-threatening issues systematically and promptly
When should you call a Code Blue?
What is when a patient is unresponsive, pulseless, or not breathing
What’s the priority for a patient with suspected sepsis?
What is administer IV fluids, broad-spectrum antibiotics, and notify the team (Sepsis Six bundle)
Define hypotension in an adult patient.
What is Systolic blood pressure less than 90 mmHg
What symptom might indicate internal bleeding?
What is Abdominal distension, pallor, hypotension, or dropping hemoglobin
When should the ABCDE assessment approach be repeated?
What is continuously or after any intervention or change in condition
What does SBAR stands for and how is it used?
What is Situation, Background, Assessment, and Recommendation
Example: A post-op patient with rising heart rate, low BP, and increased respiratory rate — you use SBAR to call the surgeon and report suspected bleeding
What is the first-line fluid for treating hypotension?
What is 0.9% normal saline (crystalloid solution)
Why is a rising heart rate with a falling blood pressure concerning?
What is it may indicate compensatory shock or impending cardiovascular collapse
What’s the significance of new onset confusion in an elderly patient?
What is they may be a sign of delirium, sepsis, or hypoxia—often an early indicator of deterioration in older adults
What equipment is essential when performing ABCDE?
What is Oxygen delivery devices, BP cuff, stethoscope, pulse oximeter, thermometer, glucometer, suction, etc.
What are our effective communication "CUS" Words
What is I am Concerned, I am Uncomfortable, This is a Safety Issue
Name a nursing intervention for a patient with a high respiratory rate and low O2 saturation.
What is raise the head of bed, apply oxygen, assess airway, notify team, perform ABCDE